Aneurysm Guy Update

He got to Cleveland, OH on Tuesday and upon reviewing his information, they said it is inoperable.  They were medically managing his pain and blood pressures.  He went into the bathroom to have a bowel movement on Thursday and it ruptured. He died within minutes.


I thought about what his final minutes were like.  The searing pain, the warmth of blood rising up from his throat, the terror of what that must have felt like, knowing exactly what was happening to him.. then I realized what came right after that initial shock of what was happening.  A peaceful surrender.. a calm sense of finality. The knowledge that very soon, all the pain will cease to exist.  Flashes of his family's smiles.  His mother tucking him in at night.  His wedding day.  The day he was told he was a ticking time bomb.  The worry was finally leaving him, the uncertainty gone. He finally knew exactly how long he had left and it was okay. It had to be; what other choice did he have?(his exact words re: his trip to OH when his family asked him what he wanted to do about having the surgery)  So he relaxed, slumped over, and let his blood pressure fall.
and I remember clearly his words to me when I was discussing the gravity of his diagnosis with him to which he said,  "We all gotta go sometime, kid.."

I really am lucky to have the job that I have.  I sometimes feel as though I am on border patrol to the pearly gates, and I feel pretty sure I will have A LOT of friends on the inside when my time is up.  Hopefully they will save me the good seats at Bingo.

Timing is Everything

I found a man face down on the hospital floor at 8:02 am on Saturday morning on my float to another hospital floor.  I saw a foot with a black sock sticking out from underneath the curtain.  I pulled back the drape and the man was face down on the floor , his IV pump whirring with normal saline fluids.  I instinctively put my hand on his naked back.. he still felt warm.  I asked him if he was ok and I got no response.  I felt for a pulse, there was none. I flicked on the light and looked at his face.  It was completely cyanotic (blue). I yelled for someone to please come in and I pulled out my handheld phone and told the operator we had a code blue (if you ever wondered why it's called a code blue... now you know).  I tried to roll him over to start chest compressions but he was too big and I couldn't do it myself. Finally another nurse arrived and a nurse's aid.  I still heard no announcement about a code blue. I called again and said "Did you hear me?  We have a Code Blue!! on floor x!!"  The operator responded with, "I'm not sure how to announce that.. I'm getting someone right now who knows.."

Um, okay.. don't you think the FIRST THING they teach in operator person school IN A HOSPITAL is how to call a CODE FUCKIN BLUE? Are you KIDDING ME?  45 seconds later I heard the announcement over the PA system and the code team arrived 2 minutes later. We got him rolled over, started chest compressions, and when we had enough people we got him up into his bed and started pushing meds while doing CPR trying to get him back.  It didn't work, he was gone too long. :(  I also was there when the Dr. called the family.  She was a young resident and her exact words were, "I'm sorry, we did everything we could, but your husband didn't make it.." then the family started yelling asking why no one called earlier (the resident called after 30 minutes of working on him).  I can tell you from past experience, typically a designated doc will break off from the code 5 to 10 minutes into the code to tell the family what is happening.  How the family knew this was commonplace is beyond me.  Anyway.. I wish the resident had reasoned out how to make this call a little better in her mind.  This gentleman's primary diagnosis was a KIDNEY INFECTION. Can you just imagine your loved one being in the hospital for an infection and you getting a calling 8:30 am that "we're sorry we did everything we could, he didn't make it"??  I am sure the resident thought she was doing everything correctly (the books say that's how you handle it) BUT, a better approach would have been to actually call a few  minutes into the code and say "Mrs. x, This is Dr. xyz from blah blah hospital. Your husband's health has taken an unexpected turn. We are currently performing CPR and hoping to revive him, please drive safely in getting here..."  This approach is better for 2 reasons.. if you call right away during the code, the patient isn't technically dead yet (or at least hasn't been pronounced dead), plus, you don't have to tell someone over the phone that their loved one has passed.  What's really distressing about this is the fact that we probably could have saved him if he were on telemetry (cardiac monitoring).  Lord only knows how long he was laying there on the floor... we would have known right away if his heart had stopped had he been ordered to wear it.  And even though his admitting diagnosis was pyelonephritis, a quick glance at his cardiac history would have shown cardiomyopathy and a heightened risk of endocarditis. (which I don't know if they were even checking for by that point).  But, I guess the bottom line is, it was is time to go because that's what his circumstances led him to.. I suspect the whole experience of that code provided valuable lessons to each of us involved and somewhere down the line a life will be saved thanks to that experience... or at the very least the blow of losing a father/mother/husband/wife/son will be softened for someone else down the line.

Enter my patient with a 11.1 (4.9 inch) thoracic aortic aneurysm.   In 2010 it was 7 cm.. it has been growing and that is NOT a good sign.  Aneurysms are notoriously deadly and having seen what it looks like when one ruptures; suffice it to say it's a horrific way to die.  Our surgeons will not TOUCH his aneurysm.  Way too unstable, way too large.  The words "ticking time bomb" are synonymous with this patient whenever we are referring to him.  When I got report on him, the hope was that he would be able to be transported to a hospital in Cleveland OH that specializes in aortic aneurysm repairs.  To look at the Dr's credentials it's pretty impressive- I definitely think they will be able to help him.  If only we can get him there in time.  On the positive side, his blood pressures have been on the low side (a high BP will surely rupture it) on the negative side I had to keep him dosed with oxycodone to help him deal with his back pain.. a sure sign that he's going to rupture at any time..  I spent HOURS on the phone with the transferring hospital's transfer dept, ICU nurses, tried to arrange air transport, medicare won't pay, family has to approve, patient doesn't want to put up cash, ALS vs. BLS transport, our nurse supervisor trying to call our case mgmnt team, no one answering, me calling back and forth to the family.  All the while getting two new stroke admissions with q1 hour neuro checks and a complete NIH scale admission and confused post hip fracture patient. Oh, did I mention I have a horrible cough, fever and a sore throat and barely a voice and that on Sunday I was absolutely unable to get out of bed? Probably because, like a dumbass on Saturday, I didn't eat or drink anything for my entire shift when I already was sick and frankly the thought of eating or drinking just didn't appeal to me.
Anyway.. it's all behind me now.. I called work, aneurysm guy is on his way to Cleveland, it's a beautiful, sunny day and I have two gorgeous children who are about to run off the school bus and into my arms.
Timing really is everything. :)

Just a few things..

Had an overall decent weekend at work. Got to go home early (1130pm) today, it was nice. I got back my patients from Saturday and Sunday and the two biggest pains in my ASS were transferred to other floors (hell YEAH baby!) And I got left with a cute 98 year old lady, an adorable 95 year old lady, a new stroke on a 84 year old lady and a PITA 55 year old lady who takes more meds than the other 3 women I mentioned COMBINED.

PITA #1 was a dude with Hep C and a bleeding disorder and he constantly had fresh, bright red blood in his mouth coming out of his gums. Plus his liver was shot so his ammonia levels were sky high and affecting his cognition and sense of balance. His gown was covered in blood, his room was a sty, he was forever pissing all over the floor and if I sound a little harsh talking about him it might be because the motherfucker HIT me in the arm when I gave him a shot of insulin in addition to calling ME a pain in the ass and looking at me with absolute venom every time I entered the room. Then he proceeded to call me a bitch every chance he had. At one point I walked into his room to give him some scheduled meds and he started saying "OH GOD, what do you want NOW!?  Jesus!" then I said, "Look, I don't want to be in here any more than you want me in here, so just let me do my job and I promise I will be getting away from you as quickly as I possibly can."  And then I hummed this song every time I was in his room:

A good patient I had was a 98 year old lady whose grandson was visiting and noticed her speech was getting slurred and she wasn't walking straight.  He called 911 and the ambulance came right away.  Upon arrival to my hospital, she was administered the clot busting medication TPA.  Within a few hours, all her stroke symptoms resolved. She was coherent, bright eyed and quite spunky when I got her.  I met her Grandson and thanked him for acting so quickly- he saved his Grandmother from an end in life that I see all too often.  She was really cute, too.  She said the state sent her a driver's license when she was 96 but she decided not to drive anymore.. not because she thought she couldn't, but because she said, "God forbid if someone ever hit me, the first thing everyone would say would be 'what was a 96 year old doing driving?!' and then I'd end up getting blamed for it.  So it was my choice to stop driving."  This little lady had more brains and sense than most 40 somethings I care for. Anyway, what I learned from her was firsthand how important it is to be able to catch a stroke in its early stages-- it's truly a medical MIRACLE what tpa can do.  I think we've all heard how critical timing is with catching and treating strokes.. but until you see it firsthand?? Just wow. Amazing.