Saturday, December 12, 2015

A young stroke pt, a bit of fetal physiology, and some pettiness on my part

I genuinely wasn’t prepared for the popularity of this blog, or for some of the sequelae that followed it. I thought a few people might read it, get a chuckle, and glide on by. So I wrote like the blog would be gone in a month, a forgotten vanity, an echo chamber for my rambling thoughts.

Instead, you liked it. Which is alien and bizarre to me, like discovering that other people really do like the smell of your farts. Are you guys… okay?

Anyway, a lot of things happened while I was on hiatus.

I launched my kid sister at the end of the summer. It was not easy and I spent virtually all my downtime helping her fill out paperwork, set up and attend interviews, and move into her own tiny room in a house where girls rent rooms to sleep in between classes. She has a job now, and passed her GED. I am so proud.

Also, I am so glad that I can flop on my sofa in my underwear when I get home from a shift.

Aside from all that, I also went to Yellowstone for five days because I was losing my mind and my first response to stress is to go camping, and I went to a cheese festival and got constipated and drunk, and I had a shitty run-in with a pt family who heard only what they wanted to hear and reported to my manager that I had lied to them. Fortunately, my manager knows that I am a thousand percent more likely to overshare than I am to conceal, and has been my facebook friend long enough to know that withholding information about medications is not something I am physically capable of doing.




Their case was very strange. The pt was twenty-eight and very fit, and had started having TIAs—transient ischemic attacks, or mini-strokes—about a month before. He had finally collapsed that morning at the gym, slurring and dragging his left side, and his girlfriend of two months insisted on bringing him in despite his protests.

There wasn’t much to do. The neuro team performed an angiogram and stented an artery that might recently have spasmed, and they sent the guy up to me for watching.

He did not do well. Even after he woke up from the procedure, his symptoms worsened, and I ended up calling a Code CVA on him—like a Code Blue, but instead of a cardiac/respiratory arrest, you’re grabbing a hospital-wide team to deal with a stroke. You have a little more time to handle a CVA (cardiovascular accident), but none of it can be wasted, and if your pt is slurring and dragging his leg and choking while he brushes his teeth, you fucking well better call everybody.

Before that, though, we had an endless shitshow of poor medical communication, and a bit of a cautionary tale.

This guy was with an HMO that partners with our hospital. Their doctors act as hospitalists, and some of our intensivists are actually their intensivists practicing in our facility, and most of the time we have no issues. But good god, the issues we do have…

The worst is that a pt can be transferred from their urgent care to our ICU without requiring an intensivist consult. You get an ICU pt whose doctor is not accustomed to critical care, whose paging system is not set up to accommodate critical care needs, and who might or might not be a block or more away from the building at any time because technically they don’t work for us. This makes the docs quite reluctant to actually come see a pt when we ask them to.

In this case, it meant delay after delay, calling and paging over and over while the pt’s symptoms worsened. When I called the Code CVA, I didn’t really think he was stroking out, I just knew that something fucked-up was going on in his head and that we needed help that wasn’t coming from the HMO’s urgent care physicians. And I was prepared to do the insane paperwork that came with the code.

There was a clot, turns out. Not an occlusive clot, but enough of a clot to cause the artery to spasm around it occasionally. Another angiocatheterization was performed to dig it out, and the pt’s symptoms resolved within a couple of hours. He was fine.

Where the fuck, though, did a clot come from? The usual suspects, things like prolonged immobility, atrial fibrillation, and chronic carotid stenosis, were all easily ruled out. My recent preceptee Anne, on her last shift before taking her own pts, pointed out that a young pt with a thrombotic stroke needed to be checked for a patent foramen ovale, and I goggled at her like a turkey in the rain. She was absolutely right. I was a complete dunderhead for missing it, and so were the HMO hospitalists. When I dragged the intensivist in for an extremely informal nurse consult, he looked at me like I’d forgotten to put on pants and asked if we’d done an echocardiogram to check for a PFO.

To understand the patent foramen ovale (PFO), you need to know that babies in utero are fucking weird monsters whose bodies work in exactly the opposite ways from how human bodies work, and that all their blood flows backwards and their veins go different ways and oh, their blood is hungry.

Yes, hungry. Their hemoglobin is capable of grabbing oxygen easily from maternal hemoglobin, which is how they oxygenate themselves through the placenta, in which their blood and their mother’s blood can meet without touching, and the fetus can steal its mother’s breath. Eventually the placenta is ripped apart and the blood mingles, and the child’s stray cells are free to invade and embed themselves in the mother, binding themselves to her brain and her flesh even while her offspring wanders free.

Meanwhile the mother’s body, betrayed by this invasion it nourished with its own blood, learns to recognize and attack whatever identifiers don’t match its own. If the child carries Rh markers and the mother doesn’t (this is the negative or positive indicator that accompanies A/B/O), the mother’s blood will learn to hunt and destroy anything Rh+ for the rest of her life, obliterating any younger brothers foolish enough to be conceived with the hated Rh. The violent fetus, the unwilling chimerical mother, the irrevocable enmity of blood meeting blood—birth is a fucking space opera inside the human body.

But none of this is happening when the foramen ovale is open. Fetal blood, hot and red from the placenta, pours into the umbilical vein; the liver devours most of it, drinking it up through the same vein by which blood is filtered from our intestines to the rest of our bodies. From here, it passes through the heart—not from atrium to ventricle to lungs, but from atrium to atrium. Between the two upper chambers of the heart is the foramen ovale, the hole in the heart, the secret door.

The atria contract, and blood passes between the two sides of the heart freely; the ventricles contract, the atria slam shut, and the left side of the heart thrusts blood out into the body as you might expect. The right ventricle would normally send blood through the pulmonary artery to be oxygenated, but the lungs are small and fluid-filled and useless, folded neatly like linens in a dowry chest, waiting for someday-air like the promise of an afterlife. No point in wasting energy, sending the blood through these tiny pitiful organs. They get a sip, a tithe of maternal oxygen to help them grow.

Instead, the right ventricle fills the pulmonary artery as normal—but there is another secret passage here, the ductus arteriosus, a shortcut between the pulmonary artery and the aorta, and the lungs are nearly forgotten as the blood rushes to join the aortic rush. The two ventricles are, at this stage, very weak and small; but united by that secret passage, fed equally by their conjoined atria, they push hard enough to perfuse the body.

Three passages that completely change the flow of blood and the hierarchy of circulation. A gate through which blood returns from the war zone of the placenta; a door by which the halves of the heart share what fills them; a passage by which the efforts of both halves are united—and their blood moves in ways that no adult could survive.

Then all that birth business happens, and the fetus emerges and is a baby. The first breath rips the lungs open and fills them with unexpected pressure, flooding the body with plentiful oxygen for the first time. The door, meeting this pressure, slams shut; the passage collapses as the body responds to oxygen with new enzymes and processes; the war-gate receives two signals—the placenta is bleeding and clotting, new serotonin signals well-being and completion—and locks itself tight. Soon nothing is left of the latter two passages but a matched set of ligaments: one for the liver, one between the aorta and the lung. And of the former, nothing but a dimple in the dividing wall of the heart.

One breath, and the whole body changes. By the time the baby screams, its chambers are estranged, and its secrets are all sealed away forever.

Unless, apparently, you’re really into crazy workouts. And this guy was really, really into crazy workouts. He was a member of a popular fitness program that thinks rhabdo only happens to sissies and physical injuries are a sign of weakness, and he had an absolutely pathological compulsion to exercise. His girlfriend and mother fought like two cats in a pillowcase the entire time, both of them screaming at each other about how he worked out too much, both of them seeming to agree but really not appreciating that fact. Before he could even speak clearly, he was asking if the hospital had a gym so he could “do some lifts,” and when we told him that he would need to take it easy for a couple of weeks while that stent settled into his healing brain, he asked how many chin-ups he was allowed to do per set and how much weight, exactly, he could lift? Two hundred, four hundred pounds? How many reps?

The limit was something like twenty pounds. He flew into a panic and worked his left side out thoroughly by throwing things all over the room. I herded his family out, made sure there was nothing dangerous close to him, and watched the tantrum-slash-panic-attack from the hallway where it was safe.

I can't diagnose this, but I suspect he had an anxiety disorder akin to anorexia, something in his brain that told him he had to be bigger and stronger than anything that made sense for health or looks, something that forced him to work out because not working out is failure. He described himself as "insanely driven" and "self-made" and "all willpower," and despite his weak limbs and unsteady gait, he continually struggled to drag himself out of bed. "I'm strong enough to get up," he said, his leg slithering out from under him as he launched himself upright. "If I try hard enough, I'm strong enough to do anything."

His full, muscle-burdened weight fell on me as he toppled. His hand, the strong one unaffected by the stroke, sank thumb-bruises into my shoulder as he struggled to regain his balance. His dread of weakness, his desperate anxiety, turned his few hours of helplessness into torture, and turned me into a piece of furniture to be leaned on as heavily as he could. I don't blame him. I saw the white edges of his lips and the look of terror in his eyes. It still hurt.

No sensible goal could satisfy him. Anything he achieved was pathetic in his mind; nothing he did was as good, as strong, as successful as it could have been, if he had been good enough-- if he had been perfect. If he sat up, he remarked that he should have been steadier; if he lifted his weak arm, he cursed at it for being pitiful; if he managed to stand at the bedside for a moment, no small feat in his condition (and certainly not a good idea), he raged at himself for not being able to walk.

He was not healthy. He was strong, and probably considered himself attractive, and certainly viewed himself as accomplished. But something inside of him was ill, and it made everything about him sad and desperate. Without that compulsion, he would have just been a young guy with a stroke, an anomaly. With the compulsion, he was a patient.

I put in for a psych consult. He was, all anxiety aside, a total asshole who didn't care when he was hurting me. His coping skills were, at best, maladaptive. The psych group said they would send someone up right away.

Anyway, when things calmed down, the echocardiographer came up to look at his heart with an ultrasound. The screen wasn’t showing anything interesting, but Anne wasn’t having any of it. “You lift weights, right,” she said. “Like, heavy weights. Can you bear down really hard for just a minute while the tech pushes this little bubble in?”

The little bubble popped into the right atrium just as he bore down with tremendous effort, like he was trying to shit not just his pants but all the pants in this hemisphere at once. I guess he thought it was as close to a workout as we’d let him get today. And sure enough, the secret door—ripped by the tremendous pressure of poorly-moderated weightlifting, standing ajar in the wall of his heart—flipped open and let the bubble pass from the right atrium to the left atrium without ever entering his ventricles.

This was where the clots were coming from. The PFO was trying to close itself. The turbulence and the injured flesh were a perfect clot-forming setup, and any clots that formed passed freely into the left side of the heart and thus into the brain, unimpeded. The clots so far had been tiny, but had irritated the shit out of his cerebral artery, causing spasms and transient ischemic attacks.

Anne caught it. I wrote a recommendation card and we gave her an award pin for her sweet as hell nursing skills. I was fucking impressed.

Possible treatments for the PFO ranged from blood thinners to open heart surgery. The appropriate tactic in this case, fortunately for the pt, involved just letting the damn thing heal, and coming back for an echocardiogram in six weeks... during which time he was not to lift weights. I felt bad for him right up until he started kicking the bed's side rail out of frustration.

The psych consult did not go well. He was so insulted that his screaming could be heard all the way to the nurse's station. The psych evaluator left, but tucked contact and resource information into his discharge packet in case he had a change of mind later.

Later on the pt's blood pressure skyrocketed during one of his freakout throwing fits, and I gave him metoprolol to control his pressure and protect his newly stented artery and his heart. Somehow the family got the idea that this drug was intended to close the PFO, and that once I gave it he would be able to get back to weightlifting (and thus stop throwing anxiety fits and full cups of ice all over the place). I have no idea how they decided this, except that they knew what they wanted to hear. Later, they complained about me to the charge nurse, claiming that I had driven him to panic, that I had promised to cure his PFO with metoprolol, and that I had told them their doctor would be removed from their case entirely when I called the Code CVA.

I’m really glad I have a reputation as a blabbermouth nurse who can’t stop educating long enough to take a dump in the morning. Charge and manager alike looked at the pt and his family, raised their eyebrows, and offered a placatory non-apology that made it abundantly clear how much bullshit they smelled. I was mad enough to gnaw the pistons out of an engine block, but I managed an apologetic smile of my own and clocked out with veins standing out on my forehead and red blotches popping up on my throat.

I think it’s the first time I’ve really been angry over an insult to myself. I generally only rage out when somebody threatens or endangers someone I care about or someone under my care. This one haunted me for a while, though. I’d worked all fucking day and thrown myself into a Code CVA, one of the most exhausting cascades of procedures and charting in the hospital, to protect this guy’s brain, and he was so mad at me for keeping him from doing his reps that he and his family were demanding that I be fired.

Whatever. You know what? He got better. His brain recovered. If he managed to stick with the recommendations of the neuro team until his stent stabilized and his PFO closed, he probably made it back to his workout program and started weightlifting again with no problems whatsoever. There's even a possibility that he got psych help, that he shook the terrible compulsion that wrecked his life and ripped his heart. So there’s my victory: he was an asshole willing to throw me under the bus to maintain the illusion of control over his body—but I was right, and because I was right he gets to eat and talk and live like a normal person, and even if he never admits it, he owes some small part of the rest of his happy life to me.

Maybe I wasn't angry for myself after all. He was, in truth, threatening the safety of someone under my care: himself, my vulnerable pt, whose body and life were at risk because he couldn't cope with his anxiety and he couldn't accept help. But he went home with a new chance at life, and that means I won.


We take our victories where we can get them. Even the petty, passive-aggressive ones.




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For more reading about the craziness of mammalian birth, this incredible article says it better than I ever could. Go forth, and discover How the Woman Got Her Period.

13 comments:

  1. > Instead, you liked it.

    Me and apparently 136 other Feedly users. I'm as confused as you are!

    But seriously, your colorful walk-through of Rh disease and the PFO *more than* demonstrates that your moonlighting as a wordsmith is not for nothing, at least to this layman.

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  2. Wonderful descriptions as always, not just of the medicine but of the social context. I'm a student doctor exploring the heart and postpartum circulatory changes for the first time in classes/workshops- my teachers make it interesting, but not as much as Elise does!

    Fingers crossed I get to work with (and learn from) nurses as awesome as she is when I'm on the job.

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  3. Best bathtub reading ever. I feel like I am ready to face my day now, aspiring to your level of kickassitude.

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  4. Yes, I like it. You _TEACH_ when you write, and I learn from your writing. I learned today about PFO, fetal blood flow, how the first PFO shuts down by the first breath, and how a PFO can re-open and do Very Bad Things. You have a lucrative second career in writing awaiting you when you retire. I come from a family of medics and engineers, and the techie aspects of your work are right up my alley. You write as much about the human aspect as about the technical aspect, too, and this educates me, too.

    Thank You Very Much!

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  5. Have you ever heard the term 'bigorexia?' It's like the (colloquial) weightlifting analogue to anorexia and I heard about it a lot while I was learning about eating disorders a while ago. I think he probably ha(d/s) a pretty serious case of it, though I know I'm armchairing. I just recognize that sort of desperation.

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    1. (Also you were totally right and I am also angry that they would be so self-centered as to potentially hurt anyone else for his reps no matter how much I love brosciencelife.)

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  6. This is amazing, though! Don't sell yourself or your patho short--I'm a biologist, and I've read a lot of good popular science, and this piece's focus on fetal nutrition and oxygenation is easily one of the best I have ever seen at accurately and memorably describing how this stuff works. These posts are a complete delight. Thank you so much for taking the time to put them on paper!

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  7. This is amazing, though! Don't sell yourself or your patho short--I'm a biologist, and I've read a lot of good popular science, and this piece's focus on fetal nutrition and oxygenation is easily one of the best I have ever seen at accurately and memorably describing how this stuff works. These posts are a complete delight. Thank you so much for taking the time to put them on paper!

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  8. Awesome read as usual. I love your writing and end up learning so much.

    Any plans for posting "that story" (you know the one)?

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  10. Unbelievably educational and entertaining as always. This is the reason we keep coming back!

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  11. I LOVE THIS. Never stop sharing your stories. <3

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  12. I believe the anorexia equivalent is called orthorexia.

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