PixelRN

As I was writing about liver failure a couple days ago, it crossed my mind that I was oversimplifying the issue. 

Kind of like this:

liver failure = death

liver transplant = life.

I don’t really think that way. I’ve definitely seen a spectrum when it comes to liver failure. It’s just that there is a certain point with the liver where it really can’t be turned around.

And just to illustrate this further, yesterday I was handed a very serious liver failure patient to care for. She was the same age as me. It was surmised that her liver failure came from a combination of an antidepressant and an antibiotic. Two benign little pills that caused this destruction. When liver failure is caused by drugs there is often a chance that it will reverse itself. This patient, however, developed sepsis, which (one) hindered her body's ability to turn itself around and (two) ruined her eligibilty for a transplant work-up.

So here I have a patient that is almost the opposite of how I was thinking in terms of liver failure. There is no "family meeting" and "withdrawing care" here. Does her liver still have a chance to reverse itself? Absolutely. And whatever organism caused her sepsis seemed to be winding down, which may soon put her in the running for a transplant.

But then two nice-sized clots in her right atrium were found. The first appeared to be a clot hanging from the tip of her dialysis catheter. The second could have been anything. Maybe even a big ball of fungus.

But doesn’t that just suck? I mean it sucks hard. There is obviously no black and white thinking in this case. It could go either way for this woman. I couldn’t help thinking that I was meant to care for so that point could be illustrated to me. I have this passion for trying to find “the big picture.” On some level I’m trying to get at the gestalt of the thing, but sometimes I wonder if maybe it’s just the desire for a shortcut. There is so much data to process for the MICU patient. You worry about treating one problem at the expense of the others. And I’m just speaking from a nursing viewpoint. I would imagine that for the residents/interns this issue looms even larger. They have even more data to assimilate, and they are the ones actually writing the orders. 

At any rate, I think I’ve finally developed the ability to care for a heart-breaking patient without actually having my heart broken. (I knew it would happen sooner or later.)

________________________________________________

On a (somewhat) lighter note…what do you do when someone other than a patient “codes” in the MICU? When a code is called in another part of the hospital, our docs are the ones that show up and run the code. Yesterday a patient’s mother “coded” twice. I put coded in quotation marks because it was more of a narcoleptic seizure. It first happened in the family waiting room. She was sitting in her wheelchair and just suddenly fell asleep. A hospital employee called a code. Twenty minutes later she turned out to be fine.

Then, at change of shift, she did it again, only this time she was in her son’s room. Someone noticed that she had fallen asleep and was unarousable. The resident started telling us that we would actually need to “call” a code because legally we couldn’t administer MICU code drugs to a non-MICU patients. (???) So who was going to bring the code drugs to us, I wondered, the code fairy? At any rate, we really didn’t need any code drugs. A nurse slapped some zoll pads on her and a took a cuff pressure and an 02 sat. Her vital signs were unremarkable. Meanwhile the night shift nurses come walking onto the unit and immediately enter into “code” action mode but there was really nothing to do.

And the son (who was perfectly fine by the way, just watching TV, waiting to be transferred) says, “She’s fine. She’s been doing this for 48 years.”

I wonder how often this woman “codes” if she’s a narcoleptic? It really was quite an amusing visual. The son (who is the patient) is sitting up in bed with this wry smile, not looking the least bit sick, (I think he was in for one of those  conditions where you appear fine but could crash any second, like hyponatremia). And the mom (who is not the patient) is slouched over on the wheelchair, hooked up to the zoll pads. The day nurses are looking bemused, the night nurses are looking bewildered, the resident's waiting for the code fairy to show up.

Finally security came and agreed to wheel her down to the ER where she could be legally treated for her condition, whatever it was, and the son went back to watching TV.  

Last year I was talking to this doctor while I was still in nursing school and contemplating working in the MICU.

"Those patients are sick as snot," she said.

I love that expression. It really paints a picture. I'm here to tell you, though, that it's not entirely true.

There is one night nurse in particular that subscribes to that belief. She’s a traveler with many years of experience. She’s the one who I referred to earlier that always sprinkles her report with comments like, “This patient is really sick. The resident/intern is just chasing her tail. I don’t know what these doctors are trying to do, but they better do something.”

Now. The first time this happened, I was fresh out of orientation. I listened with my eyes and ears wide open. When she was finished these were my thoughts:

 I’m about to take care of a really sick patient (crap).

The doctors don’t know what they’re doing (double crap!!!).

I don't know what I'm doing (TRIPLE CRAP!!!). 

Her overall attitude from the previous night had now set the tone for my day. So I tried to remain calm, get myself organized. One advantage that the day nurse has over the night nurse is this: We participate in AM rounds. This means that we give a nursing report to the team of docs (usually an attending, fellow, resident, intern and sometimes a pharmacist.) We listen to their plan of treatment, and the rationales behind everything. A list of daily goals for the patient is produced. It's all very collegial and informative and it puts everyone on the same page of music.

So I begin a three day stretch with this patient, and I know what the plan is.

I am not seeing this patient in the same way as the night nurse. Yes, she is very sick. Isn’t everyone “very sick” in the MICU? She is a lung transplant patient. That's all you need to know to understand how sick she is. Lung transplants are some of the most complicated patients you can care for in the MICU. Two medications make them this way: Tacrolimus and Prednisone. One is an immunosuppressant. So it causes the patient to be immunocompromised. Fill in the blanks for what can go wrong there. The other is a corticosteroid. They can cause hyperglycemia, osteoporosis, and bleeding just to name a few of the lovely side effects. Then there's the kidney failure associated with tacrolimus, and the ICU psychosis that always seems to hit lung transplant patients the hardest.

At any rate, when you spend three 12 hour days with a patient you are bound to see some changes. I actually saw her improve, at least enough to wake up and interact with her family members.

But now a seed has been planted in my brain. Is this nighttime nurse perhaps somewhat of an alarmist? Do I dare even think that way about someone who has twenty years experience over me? Am I perhaps not enough of an alarmist because I am not freaking out about how sick this patient is? Just some thoughts I had at that particular time.

Fast forward to 4 months later: I am getting report from the same night nurse on a different patient. This time the patient has (I’ll just name the top three diagnoses) chronic pancreatitis, myasthenia gravis, and respiratory failure (which is the main reason she’s in the MICU). But the report sounds identical to the lung transplant patient: “These residents don’t know what they are doing, this woman is so sick! This situation is dangerous!”

It’s amazing what 4 months can do. Because now I have reviewed my patient’s data, gone into the room to assess her, participated in AM rounds, and now the tone of my day is set by my own impressions, not by the night nurse's.

And my impressions are this: Yes, this woman is extremely sick. No, the doctors can’t quite figure it out why she went in to respiratory failure in the first place. Am I flummoxed? No. I have a job to do. I will be spending the day with this patient. How will it help her if I get all frantic about how sick she is?

So I cared for this patient for three days and I watched her (and helped her I hope) get better. She went from being vented, sedated, and febrile to sitting up in bed, just a little supplemental O2, watching TV with her daughter. No, she's not cured but at least she's out of the woods and ready transfer to the floor, one step away from going home.

So I start to wonder, how much does the nurses demeanor/attitude/state of mind affect the patient's ability to heal? I’ve always been of the belief that you get what you expect. With that in mind you can go to work expecting to have very sick patients that will eventually be healed (or perhaps not) or you can expect to have patients that are very sick and will just lay there hopeless in the MICU while the residents chase their tales. I choose to expect the former.

Then there is the other end of the continuum of experience. On the same three-day stretch I observed another nurse at work who is very fresh out of orientation. She was upset because she had a liver failure patient with multi-organ failure.  She was frantic and frustrated. She felt that the docs weren’t listening to her on rounds. She felt like we weren’t doing enough for this patient. I asked her if the patient was being worked up for a transplant.

"No," she said, "transplant is totally not an option."

"Is there a family meeting scheduled?"

"Yes, this afternoon."

"Well then don’t worry about it."

"What? Don’t worry about it? "

"Yes, don’t worry about it. You’re patient is in liver failure. They are going to die. Neither you, not the docs are going to fix anything. The best they can do is have the family meeting and explain this to the family. Just carry out what needs to be done and most importantly make sure she’s comfortable, make sure she’s sedated."

(And sure enough, that is what happened. Family meeting occurred, family decided to withdraw care, and the patient passed away in peace.)

Now don’t get me wrong. I’m not just sitting there all blasé in the nurses station drinking coffee thinking, why bother, all these sickies are going to die anyway. Hey you over there with the fatty liver! Quit yer whining or you'll be getting another lactulose enema! Far from it. I work my butt off for each and every one of my patients. Maybe I’ve just been told so many times that in the MICU “these patients are the sickest of the sickest” and “you will see many deaths here” to the point where, now that I’m here, it’s not quite the death bed that everyone’s made it out to be. I see people get better. It happens every day.  

Anyway, I think this cartoon really sums it all up.