Monday, July 20, 2015

Week (actually) 5 Shift 1

This facility starts its weeks on Mondays. So I typically work Fri, Sat, Sun, Mon; have Tues off; work Wed & Thurs; then have seven days off in a row. It's a pretty rad schedule.

Report this morning: one charming lady with restless leg syndrome and chronic GERD, who had come into the ER after the most severe heartburn of her life, only to discover that she was having a STEMI.

The term “heart attack” is kind of tricky. We picture a guy grabbing his chest and keeling over, or if the TV writers are extra clever, maybe the guy has some left shoulder pain and starts sweating. The medics hook the actor up to a monitor and we see a flat line—his heart stopped! OH MY VERY FUCK, WE HAVE TO SHOCK. The nurse and doctor make eyes at each other as they paddle one million kilojoules into the patient’s nipples.

This may shock you: heart attacks on television are not usually accurately portrayed. For one thing, if your heart has stopped, you are generally not gonna have the energy to clutch your chest and manfully pretend that you’re just a little out of breath. Heart attacks—we call them myocardial infarctions because that sounds more professional and cool—may often end with cardiac arrest, but kind of in the same way that digestion ends with pooping.

“Myocardial” breaks down into two words: cardiac, which I’m sure you can figure out, and myo, which just means ‘muscle tissue’. Infarct is not a word we use often in the civilian world, although we fucking should, because it means that something has necrosed from oxygen starvation. “What happened to your boss?” “He has been… infarcted.” So myocardial infarction, MI, means that blood flow to part of the heart has been cut off, and some of the tissue has died.

The surrounding tissue is typically ischemic, which is another great metaphor word that should totally be used to describe shit like traffic jams, social isolation, and wi-fi shortage. Ischemia means that the tissue is being starved for oxygen, but hasn’t actually died yet. So in any MI, there’s usually an area of ischemia that can be rescued if you get blood flow going again.

Ischemia is responsible for the pain. Dead tissue doesn’t feel like anything much, but injured and starving tissue does. If you’ve ever sat on your leg wrong and cut off blood flow to your foot, you know how much that shit hurts. Or if you’ve attempted to run a mile because you heard it’s a good thing to do, and ended up a block and a half later throwing up into your neighbor’s hydrangeas while your diaphragm insists that it’s been stabbed in the dick—which is absolutely not something I would do of course—you know what muscle feels like when it’s pushed past its ability to gather oxygen.

Weirdly enough, biologically female bodies have different symptoms. I’ve heard various rationales for this, ranging from “smaller blood vessels” to “different enervation” to “estrogen causes clotting changes” to “uhhhh lady parts are weird.” Fact is, if you were born with a vagina, chances are good your heart attack will feel more like back pain, indigestion, fatigue, and shortness of breath than the “classic” heart attack. (This scares me, because I don’t know about you ladies, but I just call that Wednesday evening.)

I would like to see some more research done on heart disease and MI symptoms in FTM transgendered people undergoing testosterone therapy, by the way. I feel like we could learn a hell of a lot about the effect of androgens on the cardiovascular system.

But I digress. The area of ischemia and infarction is really important. If there’s just ischemia, no infarct, you get angina—transient (or not so transient) chest pain that isn’t a heart attack, but should warn you that you’re in danger. If there is infarct, but only some unimportant corner of your heart muscle dies, you can still have some nasty side effects (any dead tissue, for instance, is at risk of rupturing), but you’ll probably be okay except for the loss of heart flexibility and contraction power.

If you have a chunk of dead heart in the middle of a crucial conduction path or an area responsible for a lot of fluid-pushing, you are in serious, serious shit. The bigger the MI, the more likely you are to kill off a really critical section of your heart, and the more vital it is that you get the clots dug out of your heart , like, stat.

One of the ways we tell the gravity of the dead-heart-chunk situation is by classifying MIs as NSTE-MIs or STE-MIs. A Non ST Elevation MI typically has an area, the ST segment, in the EKG—the wavy line that represents electrical activity in the heart—that is depressed, rather than elevated. The depressed line tells us that the electricity is moving slower in that area of the heart, because the cells are stressed out and can’t exchange ions quickly (remember how some ions, like potassium, belong inside the cell, where they provide electrical impulse?). If the cells die, however, they stop being machines and become dead lumps of cell-wreckage, with ions floating around their battered husks freely. And this means that transmission of electrical impulses through that area is extremely fast, because nothing is regulating the flow, because everything is dead and therefore isn’t accessing (or even delaying) that electrical signal before it’s passed on to the next glob of cells.

This is expressed on the EKG as an area of ST elevation. An ST Elevation MI is bad, bad news, and requires immediate intervention and clotbusting. An NSTEMI can often be medically managed for a while with oxygen and anti-clotting medications and vasodilators to increase blood flow, allowing the body a chance to fix its shit without having holes punched in it. A STEMI is do or die—punch a hole in the pt’s crotch, jam a long tube up their femoral artery and aorta into their heart, dig out the clot, and put in a stent to hold the chewed-up cardiac artery open before any more heart-chunks die.

The weird thing is that, after a cardiac cath procedure, pts often don’t realize how big of a deal this is. They were moderately sedated during the procedure, and there wasn’t a lot of visible cutting, and their chest pain is all better and they’re annoyed because they have to keep their leg perfectly straight while their femoral artery heals for a few hours. All the cousins visit and bring flowers and See’s Candies. They’ll be headed home tomorrow or the day after, gotta pick up a few new prescriptions on the way, remember to call 911 for chest pain or shortness of breath, back on their feet in time to make that baseball game on Friday. It’s not like they were dying.

And yet… they did almost die. Twenty years or so ago, before we had cardiac catheterization as an option, people keeled over and died all the damn time, and even if they made it to the hospital there wasn’t a thing we could do. STEMI or NSTEMI, we dumped medications into them and crossed our fingers that enough heart muscle would survive to keep them going. They would lie in hospital beds, pale and sweating and gasping for breath, gagging on ten-out-of-ten crushing chest pain, until the MI had run its course and they could either go home and wait to die slowly of heart failure, or half their heart turned black and gooey and they died. For days.

Modern medicine is nothing short of a fucking miracle.

Anyway. All that was to say: this pt was absolutely just fine, headed for home by noon the next day, eating and walking around. She was a good pairing for the other pt I picked up.

My other pt was incredibly sick. He had been some kind of college athlete once upon a time, headed for the big leagues, scouts bothering him while he and his brand-new wife tried to move into their brand-new home. Then he was diagnosed with non-Hodgkins lymphoma, dosed with chemo, nuked with radiation, sliced open to remove his spleen, and finally proclaimed cancer-free. He played his sport the entire time, but after college his health—while fairly acceptable— wouldn’t permit professional athleticism. He still holds several records at his prestigious university.

Fast-forward a couple of decades and a couple dozen hospital stays. The radiation tore him up. His esophagus was burned and scarred, and where his spleen had been removed to stop the spread of lymphoma, he now has a hiatal hernia—a weak spot in his diaphragm—and his stomach has adhered to his belly wall. He’s had a couple of heart attacks, as his coronary arteries were so damaged by the radiation that they’re all scarred up and tear and clot easily. And recently, he started coughing up blood.

A biopsy revealed adenocarcinoma—cancer, from the radiation that once cured him of cancer. His left lung was eaten up with it.

About a week ago, he had surgery to remove the cancer. They ended up removing his entire left lung and pieces of the pericardium, the fluid sac around the heart. The tumor had grown to wrap around the pulmonary artery, which made the procedure a terrifying ordeal—a millimeter off, and the pt would exsanguinate like the Black Knight. While they were removing his lung, he suffered another MI intraoperatively, and because of the severity of the surgery and the danger of fucking up his precariously snipped-and-scraped pulmonary artery, they weren’t able to perform a cardiac cath for three days.

It was a STEMI. The right side of his heart, the side that pumps blood into the lungs (or, in his case, lung), has lost some of its function permanently.

But after the cath, he started to come around. He was extubated, and managed to talk and sit up in a chair and even have a few sips of water, although his esophageal scarring had acted up again and he had developed stenosis—narrowing—which prevented him from eating.

A few days later, he vomited. He inhaled the vomit. Things went downhill from there.

A lot of people who vomit while already weak or ill accidentally inhale it. This is incredibly bad for the lungs and can cause severe pneumonia, both from the germ content of the gut juices and from the irritation of stomach acid in the lung’s air sacs. For him, the combination of slow gut movement (after anesthesia and opioid administration, a very common effect), esophageal scarring, and adhesion of the stomach caused vomiting, and his body’s weakness combined with his scarred-up throat kept him from protecting his airway. Within twelve hours, he was reintubated.

Attempts to give him a feeding tube failed. Even in Interventional Radiology, where live-action xray imaging is used to do delicate internal work, the tube wouldn’t go the right way. Important medications, like the Plavix he takes to keep his cardiac stents open, went unadministered; other drugs, like heparin, provided some protection but still left him at uncomfortably high risk. His depression medication levels lagged.

I picked him up, noted that he was pouring gross green-gray chunky secretions from his remaining lung, and alerted the pulmonologist. I’ve seen pts cough up some outrageous things, but this looked like some kind of dead flesh liquefaction business, and smelled like fish sauce. The pulmonologist grabbed a bronchoscope and a respiratory tech, and we did a bedside swish-and-slurp of his airway, sending the results off to be examined by the lab.

There really wasn’t much down there, reported the pulmonologist, just a big chunk of sticky gray shit—which came up through suction in pieces, a chunk maybe the size of a cherry pit all told, reeking like an Icelandic delicacy—and a lot of very irritated lung tissue. We did a chest x-ray, and revealed patchy white spots that indicated fluid buildup in the lungs. The pulmonologist suspected pulmonary edema, and ordered a diuretic to see if that helped his lungs clear out… but I suspected something grimmer.

Pulmonary edema—backed-up fluid in the lung tissues—typically happens because the left side of the heart is sick and can’t pump fluid away from the lungs effectively. It’s not uncommon after a left-sided MI. But this guy had a right-sided MI, so if there was a fluid back-up issue from the heart, it should be backing up into the tissues themselves, not into the lungs.

There is another condition that looks like pulmonary edema, and is, in a way, fluid swelling in the lungs. It’s called ARDS—acute respiratory distress syndrome—and instead of fluid pooling in the air sacs, the lung tissues themselves become inflamed and brittle and start to weep. The cardboard-stiff tissues are too swollen to allow blood to flow easily, and fluid backs up into the right side of the heart, blowing it up like a balloon, and causing atrial fibrillation as the nerve fibers stretch apart and start panicking and firing at random intervals.

ARDS is not a thing you want to have with only one lung.

By midmorning we performed another bronchoscopy, this one attempting to advance his breathing tube past the split between his airway branch, the place where the left and right mainstem bronchi split, called the carina. If we could get the inflatable balloon cuff down into the right mainstem, totally cutting off the left, we could increase his PEEP, forcing some of the fluid back into his circulatory system and protecting his air sacs (alveoli) from boogering shut. (Increasing the air pressure against a freshly sewn-up bronchial tube is a bad thing, and can cause rupture, which is basically the worst.)

In the end, we weren’t able to get the cuff secured in the right mainstem, and he continued to struggle to oxygenate and ventilate. Finally, in fear and trembling, we raised his PEEP juuuust a little bit.

And what do you know, he improved! Finally a fucking break for this guy.

He was improved enough that the GI doc felt safe doing a bedside EGD to try and place a PEG tube for feedings. Unfortunately, between his hiatal hernia (stomach not where it should be), his esophageal stricture, and the adhesions, the only place that was available to stick a tube through would have gone through the wall where all the arteries are. You can imagine how excited we were at the prospect of blindly cutting into a forest of arteries on this guy. Instead, the GI doc fed a small-bore feeding tube along the scope, and just like that we had access for his pills again. Not a moment too soon—his anxiety when he woke up was out the roof. I ended up grinding a Xanax into powder and flushing that down his feeding tube.

Oh yeah—this guy is poorly sedated. We have him on a shitload of fentanyl for pain, but his hospital course has been long and ugly, and opioids don’t work as well for him as they used to. We’re also using precedex, a newer sedative that’s not supposed to contribute to delirium or cause hypotension, but which the average ICU nurse will tell you is almost as effective as plain saline at sedating a really agitated pt. I asked if we could start him on some propofol, and got some bullshit about the danger of prolonging his QT interval—the time it takes his heart to repolarize and be ready for the next beat—even though we have him on a kajillion other QT-prolonging meds. I just bolus him a huge dose of fentanyl every time I plan to do anything to him, and dosing him with all the grudgingly-metered benzos and low-level pain control meds (tylenol, toradol) I can scare up by jumping out at doctors from behind the printer.

His nausea issues have been a fucking thorn in my side. With his guts all backed up, he can totally puke around the breathing tube, although his airway will be protected… but a newish surgical incision is not a fun thing to strain against while you’re vomiting. Also, I am not a fan of all the pressure jackery that comes along with dry heaving, especially with that left mainstem all delicate. I’ve been giving him a ball-ton of Zofran, which usually helps with the nausea… but it’s not doing a lot. The docs have me giving him scheduled Reglan, which stimulates gastric movement and reduces nausea, but it doesn’t seem to be very helpful, and has the potential to interact with his SSRI (as would any of the stronger anti-nausea meds). I’m giving him some truly thorough oral care, for the most part, and trying to avoid stimulating his gag reflex any more than I have to.

In the midst of all this, I traded pts at 1500 during afternoon shift change. Somebody else got my lovely STEMI lady, and I picked up a complete train wreck of a family whose grandfather has been treated uselessly for glioblastoma, a brain tumor that has negligible survival rates. They’ve put him through everything anyway—chemo, gamma knife, you name it. He’s slowly losing control of his body. His family is of mixed faith, mostly Farsi speaking, and the faith conflict has been… incredibly tricky. As a result, he’s just lying in the ICU slowly choking on his secretions while the family fusses about him, providing tons of supportive care and love and also fucking with all his equipment and doing batshit crazy things like stuffing his oxygen mask straps with tissue paper to keep the loose elastic from irritating his face. All the air whooshes out over his forehead and he starts gasping, so they plug the edges of the mask with more tissue paper. I walked in there about 1700 and thought that poor fucker had been mummified. They had also poured medicated antifungal powder all over his body, patting it into his thick pelt of body hair until he looked like some kind of gigantic Versailles pompadour or a guinea pig making a nest in a brick of cocaine.

At one point I walked in and found three of them crowded at the foot of the bed, fighting with each other about God and about whose caregiving was the best as they clipped and filed his toenails, which were grisly. I backed out of the room and left them to it.

Their behavior is just fucking bizarre. They fight and snivel and guilt-trip each other and assume martyred postures and heave endless rubbery sighs as they make up new and ever-more-intrusive ways to take care of their grandfather, who looks more and more uncomfortable as they tape towels to his hands and smear vaseline in his eyebrows and fiddle with his foley catheter so that it pulls against this side, then the other side, then this side again, of his urethra.

Apparently a number of nurses have fired them. I am well-accustomed to families from that part of the world being very involved in pt care, distrustful of American doctors, and deeply invested in the possibility of their family member recovering even when chances are slim. That can be challenging, because American medicine is not really set up to accommodate that spectrum of cultural needs, and anybody who’s worked in a hospital can tell you that pts with a thick accent are more likely overall to have their questions and requests ignored. But it’s not really something to fire a pt for—it’s something to learn a new cultural language for.

This is totally different. These people are an unhealthy family of whackjobs with irreconcilable differences who are held together entirely by the tenuous glue of their grandfather’s chronic illness, which they use against each other as a weapon, struggling to maintain control of his condition by being the most caretaker at any given point. His body is a family battleground. Thank goodness he’s mostly zonked and doesn’t have to be awake for this bullshit.

Abd guy has been making tenuous progress. His abdomen is mostly closed except for a wound vac, and he was able to wake up during my camping trip and follow commands. As far as I can tell, nobody has checked him for methanol intoxication yet. I floated a hint to his nurse, although I’m not sure at this point it will make much of a difference. His anion gap acidosis rages unchecked. I’m impressed that he’s alive, let alone progressing; his necrotizing pancreatitis is severe. I’m not exactly holding out a lot of hope for him, but who knows?

If I had to choose only one of them to survive, I'd rather see my pneumonectomy guy live than my abd pt, which makes me feel a little guilty. They both seem like nice people, but the abd guy is a single dude with a distant family—still ignorant of his condition, none of them in contact yet—and a crippling chronic addiction problem that will make his recovery process hell for him, while the pneumo guy is just an unlucky dude who got cancer as a young adult and who has kids and a wife who will be devastated when he’s gone.

But hey, if I could choose who lives or dies, I’d throw Crowbarrens out a window and chuck his wife after him and let both of these guys live. I would be a dread god of capricious benevolence.

Crowbarrens isn’t back yet, and every day he stays gone, I’m a little more antsy. I can’t believe we sent him home last time with his wife—did I mention this? She brought him in on a Friday because all their daytime home health nurses were taking the weekend off and his wife, who performs all care for him at night and while the caretakers are gone, called the police and said that if she had to spend the weekend with him she would murder him and then kill herself. She spent the weekend on our psych unit and he spent the weekend on our ICU. AND THEN WE SENT HIM HOME WITH HER. That will go over really, really well if she actually does murder him. Or if there’s a welfare check and he tells the police what she said last time. Or, basically, if anything happens to him at all, we are getting reamed like half a lemon by Adult Protective Services.

I cornered my manager and delivered a frothy screed about risk management and liability and the extent to which I do not want to lose my job because the ICU got sued down to the baseboards and is now too poor for indoor plumbing. His eyes bugged out a little bit. I think this is the first time he’s seen me in warpaint. It’s good for him, probably. I hope he doesn’t start dodging me behind corners.

Three days on, then one day off, then two more days on. Then I go camping again, because I have a Problem.

God, I hope this one lives. He probably won’t, but I hope he does.

1 comment:

  1. Thank you for heart attacks 101! I am a biology teacher, raised by an RN, but there's a lot in there that I just did not know. I also love hearing about your interpersonal strategies, that would make an amazing tutorial too!

    ReplyDelete