Making the Transition

Jerry had been on our floor for a little over a week, maybe a bit longer.  And he wasn’t getting any better.  In fact each day he seemed to get worse.  Small gains would be erased by further declines.  The anitbiotics weren’t doing their thing.  He was lucky to keep his O2 sats above 90% even on 10L high-flow nasal cannula.  It seemed like all he had to do was turn his head and he would de-sat into the low 80’s and take 10-20 minutes to come back up.

Unfortunately for Jerry his run with usual interstitial pneumonia was nearing its close.  His lungs were so scarred and fibrotic that there was nothing we as health-care providers do, except to place him on long-term ventilation, something which he had frequently and definitvely said he did not want.  One day he made his decision:  he was going to die,  Jerry wasn’t my patient, but I had interacted with him, albeit briefly, but understood from those interactions that this was a man who knew what he wanted to do and to continue living like this was not one of those.

I arrived at work the other night and the day charge nurse said to me, “We’re going to help Jerry die tonight.”

“What do you mean?”  I asked.

“He made the decision that he’s going to take off his oxygen and let nature take its course.” she said.  “But we’re going to make him comfortable and treat his symptoms.”  she finished.

“So everybody is on-board with this?  They’re not going to ry to change their minds half-way though?”  I asked.

“No.  The family is here, they’re in the process of saying good-bye.  Even his doc, who came out of the room crying today after he made his decision, is behind him.  I think everyone knows what he wants and are accepting that.  To help with that though I did staff you up a nurse.”  she said trying to put a spin on it.

I was still processing the idea.  I know that we’ve had comfort care patients who we let slip away, but never had someone who was completely lucid and in control of their faculties tell us to let them die and for us to actively help him make the journey.  In a strange way I was almost proud, can’t really find a word that describes how I felt, of Jerry for actively deciding how he was going to end his battle.  Instead lingering in an ICU, hooked up to a ventilator with nearly no quaility of life, he decided to take matters into his own hands and say, “This is how, this is when it is going to happen.  Finally, I’m in control.”

The nurse who had taken care of Jarry for the previous couple of nights was back again.  I hoped that she would be willing to take this on, but I knew she wouldn’t refuse, even if she was ucomfortable.  I saw her as she left the locker room and pulled her aside.

“I have to talk to you about tonight.  Jerry is planning on dying tonight.  I thought since you have a relationship with him, having taken care of him for the last couple of nights, you should get the assignment.  He’ll be your only patient and I’ll be your back-up and runner.  But, you have every right to refuse this.  I can’t force you to take this on.”  I siad as I laid out the situation.

“No, I can do it.” she replied.  “We don’t have that great relationship, it’s not like we’re friends, but you’re right, he knows me, is comfortable with me and I think that would be most appropriate.  Besides who else would step in?”

“Me.” I said.

“No, I’ll do it, what is going to happen?” she asked.

“Basically he’s going to let you know when to take his oxygen off and let things go from there.  You have medication orders for anxiety and dyspnea, so you can keep him comfortable and peaceful.”  I said.

We went off to start the shift and get things going.  She came up to me a little later and said, “I just talked to the doc who is covering tonight and he explained everything to me.  He even asked me if I wanted him to stay…it was a little surreal.  He did give me his pager and said if I wanted help, or needed support, he’d be willing to even come in to help.  Right now family is in saying their good-byes.  I’ll let you know when we decide to start.”

A little later she started.  She spent hours at his bedside, sitting with family and him reminiscing, learning about Jerry as he slowly started to slip away.  She would turn down his oxygen, give him some meds and wait for awhile and do it again.  About 1am she came out to both reload and take a break.  She said, “He’s hanging on.  He’s kind of Cheyne-Stoke-ing, real shallow, so when his family slipped out awhile ago I checked some vitals, he was 50/30, sats of 35%.  The doc had said it would be fairly quick, but I guess he’s hanging on for something.  I feel like there’s something else I should be doing. I mean, I’ve never done this before.  Is there something I’m missing?”

“I don’t think so.” I said.  “Maybe he’s not quite ready to let go.  Maybe give him anothe dose and let him sit with his family alone for awhile.”

And that’s what she ended up doing.  He had started to gasp a little so she gave him a dose and then left the room.  Sure enough about ten minutes later she went in to check and the family told her he was gone.  Normally we call the houe docs right away to pronounce, but with family at the bedside I decided to give them some time.  In the end we called the doc, who was a bit perplexed about why we called him, even more so why Jerry had decided to do this, but came and did his part in the end.  As part of protocol I called the attending who had told us o call if we needed anything to inform him and he asked how it went and if he was comfortable to the end.  He cared enough about Jerry to give him the dignified death he deserved and make sure it wasn’t a traumatic death  and he did a good job.

Helping Jerry make the transition was strange.  So often we’re going for the opposite, even when people are at the end we try to prolong life as much as we can.  But Jerry didn’t want that.  He didn’t want to live out the rest of his days on a vent, with lines and tubes coming out of him.  He chose how he wanted to go.  And that’s so rare.

Funny Quote of Last Night

“Who cares about HIPAA anyway?  The FBI is listening in on all of our phone conversations so there’s no confidentiality anyway.”  said by the self-confessed ultra-liberal near-socialist float pool nurse.  I’m thinking about getting her a tinfoil hat and a prescription for Haldol the next time she works with us.

It was either that or, “banan-anan-anana..” as uttered by the dude with horrid expressive aphasia.

Real posting to resume shortly.

Weather Wimps

For a place with such relatively mild weather, we here in Oregon tend to complain a little too much about the weather. I mean really, it rarely snows, it rarely gets over 100 degrees, no tornadoes, no hurricanes, but let me tell you, when something happens it’s like the Apocalypse.

Last month, we had a snowstorm.  Actually several snowstorms, that left at most 16″ of snow over the course of several days.  Of course leave it to the news to label this phenomenon of the *cue dramatic music* Arctic Blast 2008.  Yes, it was a mess.  Icy roads, bitter cold with a biting wind and the town acted like we were transported to the Arctic Circle.  What made things worse was the hysteria stoked by the news media and the inability of our local governments to effectively manage the roads and related infrastructure.  I lived in Flagstaff for 3 years and had several times where we  got over a foot of snow in less than 12 hours, but the town shut down only once and that was because we got 3 feet of snow in a 24 hour period.  That really is near cause for hysteria.  But the only people in hysterics were the tourists from the Valley of the Sun.

But it’s always the same.  Whether it is “Fall Floods ’07”, or “Heat Wave 2008”, “Arctic Blast” or the soon to come “Floods of 2009” on the news media whips us into a frenzy.  For days on end the local channels had nothing on but news, relating the same stories ad nauseam and bringing the dire reports of more nasty weather to come. All it takes a little change from the normal for them to start the dire warnings.  One anchor in particular is never happy with the weather.  When it rains a lot she complains about the lack of sun, but when it has been sunny for a long time she complains about the lack of rain.  She always has a snarky comment about the weather.

But I love it.  I was out in the weather on my bike nearly everyday of it.  I rode to work all but 2 days of the storm that I did work.  My co-workers looked at me in disbelief when I walked in head-to-toe in my foul weather gear.  But really, it was just another day.  No weather wimp here!

Not a Good Thing

It’s how my A&P professor used to classify the problems that could happen to the human body.  It was either OK, or not a good thing.  I’ve learned all sorts of things that surely fall into the latter category, hell, we see that all the time.  Then there times where you foresee the worst possible, but the reality is that it isn’t that bad.  All things considered.

Case in point.  Complete (3rd degree) Atrioventricular [Heart] Block.  Just saying makes my heart rate speed up a bit.  All sorts of bad situations run through my mind.  The ACLS algorithim for bradcardia and PEA jump to the forefront of my memory as I see it pop up on the monitor screen as the “Oh SHIT!” alarm starts ringing for bradycardia.  You run into the patient’s room and they’re sitting there, alert, talkative and having a fine time.  “Do you feel weird?” I ask.

“No, why?” he says.

“Your heart is doing something funny.  Sure you feel OK?”  I continue.

“Oh, that,” totally nonplussed,  “Naw it happens all the time.  I’m used to it.  That’s why I’m getting a pacemaker tomorrow.”  he finishes.

Then I remember the words of my EKG teacher:  sometimes we treat the monitor, others we treat the patient.  The key is to figure out which one is which.

So here’s the first strip:

3rd_degree31

Atrial rate: 80’s
Ventricular Rate: 60’s
Notice how the P-waves march through without any regard to the QRS complexes, except in beats 2 & 6.  Beat 6 appears to be preceded by a compensatory pause, where the conduction system appears to reset.  One could argue that this may be an extreme case of 1st Degree AV Block, but if you measure the P-P ratio you can see the march of the P’s, into and through the QRS complexes.  While it’s not a complete block, as some impulses do seem to carry through and you do have some time spent in sinus rhythm that I couldn’t scan in, you can tell the conduction system in not well.

Now a second strip:

3rd_degree1

Again, the atrial rate is in the 80’s, and the ventriclar rate is inthe 50’s.  Notice how the overall strip seemes to be stretching out, or slowing down.  The 5th beat is a PAC, but again, no reset happens.  After that you have a lone P-wave followed by a second P-wave with no QRS to be seen.

Pretty much in this case, the atria and ventricles are not working together at all.  At times there appears to be some synchrony, but whether that is coincidence can’t be seen in short rhythm strips like this.  For some reason I really dig on the heart blocks.  Some of my colleagues have a hard time getting their heads around the concept, but it makes perfect sense to me.  The short of it is that the top of the heart and the bottom are not communicating effectively, kind of like a dysfunctional family, or couple.  (really, AD’s description of the heart blocks is both incredibly informative and hilariously funny, but it makes so much sense.  Maybe I just have a dirty mind though.)  By the time you get to 3rd degree (or complete) heart block, the atria just does its own thing, usually clicking along at the normal rate for the SA node (60-100 bpm) while the ventricle clips along at its own rate, usually either junctional (40-60 bpm) or idioventricular (20-40 bpm).  The ventricular rhythm is determined by which escape pacemaker site is supplying the impulse, the AV node or  the His-Purkinje system.

In cases where the patient is asymptomatic, the are several things nurses can do.  First, keep them on tele for crying out loud.  Don’t let them leave the floor without an ACLS certified nurse.  You say, “Well, duh.”  To which I say, “You think this hasn’t happened?”  Second, either have transcutaneous pacer pads on the patient, or at the very least at the bedside.  Third, make sure they don’t get any nodal blocking agents, like metoprolol or diltiazem.  Once again, “Well, duh.”  Again, “You think, aww screw it…it has happened.”  Fourth, make sure they have at least 1 IV site, that works, preferably 2.  Finally, make sure Cardiology is involved as the ultimate fix is a permanent pacemaker.

Lucky for us the gent in question stayed hemodynamically stable through the night and ended up getting a new brigh and shiny pacemaker implanted the following morning.  It could have been far worse, for sure.

Emedicine’s article:  Heart Block, Third Degree

The ECG Blog has a great couple of case studies of this phenomenom, complete with 12-Lead tracings.  The latest, Complete (Third Degree) Atrioventricular Block with Junctional Escape Rhythm, is pretty darn cool, and it has our most common complaint in folks with this, “tiredness.”  Classic.

Dedicated to Sidney Sinus Node and Viginia Ventricle…

Difficult Answers

Braden over at 20 out of 10 had a great meme, Answers to Life’s Difficult Questions, and being a sucker for a meme I had to partake. So here goes.

First the rules:

1. Put your media player on Shuff​le.
2. For each quest​ion,​ press​ the next butto​n to get your answe​r.
3. You must write​ down the name of the song no matte​r how silly​ it sound​s.
4. Put any comme​nts in brack​ets after​ the song name.
5. Tag at least​ 10 frien​ds.
6. Anyon​e tagge​d has to do the same,​ becau​se fun point​lessn​ess sprea​ds like a virus​.
7. Ignore rules 5 and 6.  They are dumb. (okay, I added that one)
8. Rule number 3 kinda sucks, too.  Instead, keep going until you find the first song title that makes an interesting answer (even if it isn’t accurate).
9. If you obey rule 8 then you don’t really need rule 4.  It is more fun if people can figure it out for themselves.
10. No random and pointless meme shall have less than 10 rules.

If someo​ne says,​ “Is this okay?​”​ You say?
Take a Joke America (Carlos Mencia)

How would​ you descr​ibe yours​elf?
I’m So Lonesome I Could Cry (Hank Williams, interpreted by Me First and the Gimme Gimmes)

What do you like in a ​girl?
I’m In Love With a German Film Star (Passions)

How do you feel today​?
Fuck the Kids (NOFX)

What is your life’​s purpose?
I Wanna Be Sedated (The Ramones)

What is your motto​?
No End In Sight (Mudhoney)

What do your frien​ds think​ of you?
Franco Un-American (NOFX)

What do you think​ of your paren​ts?
Comfortably Numb (Pink Floyd)

What do you think​ about​ very often​?
Pudding Time (Primus)

What is 2 + 2?
Woke Up This Morning (Nickelback)

What do you think​ of your best frien​d?
Patience (Guns N’ Roses)

What do you think​ of the perso​n you like?
Life is Sweet (Chemical Brothers)

What is your life story​?
You Don’t Know How It Feels (Tom Petty)

What do you want to be when you grow up?
Wandering Star (Portishead)

What do you think​ of when you see the perso​n you like?
I Can’t Help Myself (4 Tops)

What will you dance​ to at your weddi​ng?
Pale Green Stars (Everclear)

What will they play at your funer​al?
Gone Away (The Offspring)

What is your hobby​/​inter​est?
Sound is Vibration (Atmosphere)

What is your bigge​st fear?
Something’s Got to Give (The Beastie Boys

What is your bigge​st secre​t?
Bitch Please (Eminem)

What do you think​ of your frien​ds?
Wicked Sensitive Crew (Dropkick Murphys)

It’s funny, I almost hewed to the rule exclusively.  Maybe my taste in music does define me.  So now I know I supposed to tag people to participate, but I’m more of a free-will kind of person.  And since I appropriated this as well, consider yourself tagged.

New Years Bit and Pieces

I’m not going to get all weepy and sentimental over the New Year.  No Top Ten Lists.  No witty remembrances of the year gone by.  No blow-by-blow details of the previous nights’ debauchery.  And definitely no overblown delusional under-thought out resolutions. Just some random bits and pieces, nothing by themselves to warrant a full post, but taken together enough to warrant a read.  Maybe.

“It’s better to burn out than fade away.”  Adios’ Monkeygirl.  That giant sucking sound you heard was the blog-o-sphere adjusting to your absence.  Hope you come back.

I resolve to proofread my postings.  I went and read through some recent posts and realized I need to proofread.  Frequently.  Before I hit “Publish”.

I love Portland.  Even though this year there was no official New Year’s celebration in Pioneer Court House Square, probably a thousand of us gathered nonetheless and had our own impromptu celebration.  Singing, yelling, the countdown, the dude mooning the crowd with gold lame’ drawers on, a true “Keep Portland Weird” New Year’s.  And the raucous singing on the MAX ride home made it even better!

And to everyone out there:  Happy New Year!