Difficult Questions

The burn unit is full of some sick patients right now, it's draining the staff. We go from very low acuity to very high acuity in literally minutes...all it takes is one spark and POOF! suddenly we are full.

As if the high acuity isn't enough, as the weather gets nicer more and more people are calling out "sick". Have I ever mentioned how much this urks me? I've been at my job almost a year and despite having 12 sick days to use, I've never called out. Sorry, I'm going off topic.

Back to my story. Last weekend I admitted a 74 year old man with a history of hypertension, diabetes, BPH, and end stage renal disease (ESRD). A few years ago, he agreed to having a fistula placed "just in case" he ever needed it. Why someone with ESRD didn't start dialysis, I'm not sure, but I wasn't there. We admitted him for a 4% 3rd degree burn to his left lower leg after he spilled hot water on his leg/foot. His diabetic neuropathy prevented him from realizing how bad the burn was and delayed seeking treatment until his family noticed his skin sloughing and oozing through his pants a few days later.

During his admission history, he seemed a bit foggy, slow to speak, and unsure of himself. The son and patent's sister accompanied him and they were very pushy and quick to answer for the patient. I kindly reminded them that I was asking the patient the questions, but that I would be happy to allow them to fill in the missing details at the end of history.

Come to find out the patient agreed to get the fistula, but the family persuaded him not to start dialysis because it wouldn't be convenient (for him? or them? WTF). I drew his baseline labs and inserted a nice fat IV into his right forearm (always a feeling of success!). When his labs came back, I was floored. His BUN and creatinine were sky high, no wonder this man was foggy mentally. I suggested to the fellow that we get a renal consult and we did. However, the family remained adamant that they didn't want the man to have dialysis. Normally, we would defer to the patient, but by the time he was seen by renal the following morning, he was lethargic and barely arousable.

Follow up labs showed even grimmer results; this man was in an acute flair of chronic renal failure. In 24 hours he had made only 100cc's or urine. As a baseline comparison, you and I make at least 1000cc's of urine a day. The patient was exuding a horrendous odor-acetone/uremic breath. Urine was essentially circulating throughout his body. My 3rd day taking care of the man, he was really decompensating. His leg needed to go to the operating room, the skin looked like this; however, until he was hemodynamicaly stable he wasn't going anywhere. To make matters worse, this mans lungs were filling up with fluid. He had coarse rales and crackles (click to listen). When the family finally arrived in the afternoon, it was the first time I saw even a glimmer of concern...maybe that's because he was gurgling, lethargic, and only responsive to pain.

I had already discussed with the attending surgeons and residents the need to possibly go though the ethics committee to get this man dialysis, but thankfully we didn't have to go there. The family agreed to emergent dialysis. We set up dialysis for that night. When I came back the following morning, the patient looked slightly better...no longer gurgling, and was at least oriented to self. Apparently when dialysis is first initiated they like to complete 2 sessions in less than 24 hours, so less than 30 minutes into my shift, dialysis arrived and set up in the room. We figured that we'd take advantage of dialysis and transfuse the patient with 2 units of blood, seeing his hematacrit and hemoglobin were also alarmingly low, but we didn't want to give him excess volume. The blood arrived and we followed protocol to a "T". We performed the 2 RN check 3 ways confirming the patient, the donor, the type, the expiration....all set and ready to go!

Being that I work in an ICU, our patients are continuously hooked up the he monitors, but I still never wander far when they are receiving blood. I initiated the infusion protocol for vital signs. The patient remained stable throughout the first 65 minutes of the infusion. Just as the first unit of blood was finishing up, I noticed the patent's heart rate shoot up into the 140's, his systolic blood pressure was 190, and he was breathing at a rate of 45 breaths/min. The patient was minimally responsive and posturing, but not like what you would see with a seizure. His fists were clenched and he was rigoring.

I yelled for the resident to come in. I grabbed my stereoscope and listened to his lungs, immediately thinking that he might have threw a clot resulting in a pulmonary embolism, but his lungs sounds were no worse than before. We immediately stopped dialysis, I ran and got the EKG machine and did one STAT, we drew an ABG, got a chest xray, threw the patient on a 100% non-rebreather face mask. I ran and grabbed the intubation box and the code cart...wasn't quite sure where this one was going. We all remained in the room and stood by. We sent off STAT labs and waited. We were ready to intubate if the patient lost his airway, but within 7 minutes, his HR slowly decreased and his BP's creped back down. We avoided giving any medications to control the heart rate because we wanted to rule out MI. 20 minutes after the patients condition seemed to be resolving, I did a follow up EKG. It looked better than the first one, as that one showed some ST wave depression.

Whew, good thing I wore my strong deodorant to work! Recognizing that this could have been a delayed reaction to the blood (delayed due to the dialysis) I drew repeat labs and sent them to the blood bank as well as filled out the possible reaction paperwork. Things settled down but I still watched this man like a hawk (did I mention that I had 2 other patients to care for?) The remainder of the afternoon was uneventful until the family showed up.

*Oh yeah, forgot to mention that when all of this was going down in the morning the son happened to call. When we asked him to clarify his fathers DNR/DNI status, he didn't even seen concerned. If you were told that you parent was possibly about to be intubated, wouldn't you try and come to the hospital or at least call and follow up? *

The family hadn't been there 10 minutes when the patient suddenly began gurgling and breathing very shallowly again: 7 breaths/min, 6 breaths/min....oh boy, I know where this is going. I stood by and roused the patient. He would breathe at a rate of 10-12. That's when one of the sisters called me out into the hallway, frantically, and asked the loaded question: "Are we loosing him?" The look of fear and dread in her face was immense. I wanted to look at her and yell, "Well if you hadn't been so selfish an let the poor man get dialysis, we could have avoided this!" I took in a slow deep breath, put my hand on her shoulder and said, "I wouldn't say that. Like most of the patients here, your brother is sick, but he's in the best place possible for someone with his condition. I understand that as his family, it must be very difficult to sit back and see your loved one look so helpless and sick. But this is our job, we do this everyday. I'm here to advocate for your brother, and make sure that he gets the best care possible. We will do whatever we need to provide him with the care h needs for the best possible outcome. I know it's scary, but we encourage you to remain active in the patients plan of care. We're not only here for the patient, but we're here for you as well."

I no sooner finished and thought, did that really just come out of my mouth? haha. I was amazed that I was able to set aside my anger with the family to remain professional.

The family seemed okay and I turned around to go check in on my other patients. However, before I could walk away, the charge nurse and resident came up to me and said, "Well done. you handled that like a veteran."

And that's how my day ended. It seems like I grow into my professional role more and more everyday. Less than a year ago, I was afraid to answer the phone at work, but in just 11 months I've come into my own and learned how to answer the much tougher stuff.

Thanks for reading!