A
Shift in the Life — The Ongoing Story of a Critical Care
Nurse
“The
Dead Horse” -- Part 2 — by Matthew Nathan
Castens, RN
As
I finished up getting report from the night charge nurse,
I looked at who she had assigned to be Bette's nurse (all
names have been changed). It was Kellie. Great! She was new
to critical care, but was an excellent thinker and agressive
question-asker. I like that in the nurses I work with -- it
makes life easier for all of us.
I
walked into Bette’s room to assess the situation. Grim
was the verdict. The nephrologist had just left and had written
some new orders: wean off the dopamine and start an epinephrine
drip.
Epinephrine
is the same as the body’s natural adrenaline. The advantage
to using it over the dopamine was that it could help the heart
squeeze better than the dopamine, and with Bette’s damaged
heart, it needed the bigger boost that the epi could give.
The disadvantage is that it would make her heart rate even
faster and use more oxygen. Like the dopamine, it was the
lesser of two evils.
As
I explained all of this to Kellie, she hung the epi drip and
slowly started to wean off the dopamine. All was going well
until the dopamine got down to about 10 micrograms. (Many
critical drugs are so powerful that the doses are in micrograms
-- one-millionth of a gram -- rather than in milligrams. Some
newer drugs are even dosed in nanograms -- one-billionth of
a gram!) When dopamine is at the higher doses(10-20 mcgs)
it not only helps the heart contract stronger, it also helps
the blood vessels constrict. When Bette's dose of dopamine
got too low, her blood vessels opened up and her blood pressure
dropped too low. Now what? I asked Kellie how she thought
things through. I do this will all new nurses I work with
so they have an opportunity to learn. I also figure that if
everyone is thinking aloud everyone benefits. Her first instinct
was to turn the dopamine back up, which was correct, but we
needed to go one step further. As Bette's sepsis worsened
and her blood became more acid the dopamine wouldn't work
as well. Also, in order to get the vasoconstriction needed
from the dopamine, we would also be stressing the heart more
in combination with the epinephrine. We needed a powerful
vasoconstrictor that wouldn't stress the heart: Levophed.
Levophed
acts the same way as the body’s norepinephrine as a very
potent vasoconstrictor. We suggested this to the nephrologist
and he immediately agreed that it was needed. Levophed is
so powerful that it is almost always the last-ditch drug to
maintain blood pressure -- especially in sepsis -- hence its
nickname, “Leave-em-dead”. In this case, I couldnt
agree more.
Once
we got the Levophed on and the dopamine off, Bette’s
blood pressure started to stablize. I went off to round on
the other patients in the unit and Kellie mentioned that she
was going to "shoot" a cardiac output. Using the PA catheter,
sterile sugar water of a known temperature is injected into
the bloodstream traveling through the heart. The PA catheter
has a temperature probe on the end of it and senses when the
blood temperature drops to the temperature of the water. The
speed at which this occurs allows the computer to figure out
how well the heart is pumping, including how much blood is
pumped with each stroke, the degree of vasoconstriction in
the body, and the patient's fluid status.
Bette's
cardiac output was as lousy as I expected. Her blood was so
acidodic that none of the medications were working as well
as they should have. We gave her some sodium bicarbinate to
try to reverse the situation. We did to some extent, but not
to the point where it would make a difference. The doctor
had just finished talking yet again with the family. Half
of them wanted to let her die. Unfortunately, the half with
the legal power still wanted to try everything. The doc came
back to us with a report. There was one last -- very last
-- chance to turn the tables: CRRT.
Continuous
Renal Replacement Therapy is amazing. It can best be described
as a super-dialysis. Unlike conventional dialysis, however,
CRRT more closely mimics the human kidney and is able to remove
toxins from the blood that conventional dialysis cannot. Some
of those toxins are refered to as cytokines, which are the
poisons that make sepsis so dangerous. If we could use the
CRRT to remove the cytokines in Bette's bloodstream, her body
would better respond to our treatments. A dialysis catheter
was placed and we planned to procede.
CRRT
is complicated. For the first several hours at least (frequently
as long as the patient is on CRRT) two nurses are needed to
care for one patient. One nurse does the calculations and
runs the CRRT machine, the other focuses only on the patient.
Beside myself, the only other nurse that shift trained in
CRRT was Marsha. Marsha and I get along quite well, but I
can see how she might rub others the wrong way. She has a
strong personality and tends to make unsolicited (but very
good) suggestions. As she went into the room to set up, I
realized that she and Kellie would not get along well. Great.
This would be another situation for charge-nurse Matt to handle.
I
pulled both Kellie and Marsha into a private room for a chat.
Basically I told them to get along or else. Or else what?
No one asked. Or else nothing, really. I did point out though
that neither Bette nor her family would be well served by
having two nurses snipe at each other over the bed. They agreed
and Marsha went to set up her machine.
Kellie
had another problem. She felt that Bette's situation was futile
and that continued care was unethical. She wanted to be relieved
of duty. I agreed but told her that there was nothing I could
do. Our unit (and the hospital) was so busy that I couldn't
get another nurse to take over. I also pointed out that realistically,
Bette wouldn't survive much longer and that soon Kellie's
nursing skills would shift from care of patient to care of
family -- somthing that she not only excelled at, but found
very fulfilling. As we went back to the room, we realized
how right I was. Marsha took Bette's temperature for her calculations
and got a reading of 105. I immediately suspected a neurological
source. Bette had had a fever before now, but never this high
-- and so fast! When the brain is severely damaged, either
by trauma or illness, the temperature center short-circuits
and severe fever results.
As
Kellie shined a flashlight into Bette's eyes, it was confirmed.
One of her pupils had grown as large as it could get and wasn't
reacting to light at all. This "blown" pupil was the sign
of herniation: Bette's brain had been so damaged by the illness
that it had swollen up and was squeezing through the hole
in the base of her skull. She was dead.
As
a group we all sighed, "Finally," and went silent. Kellie
went into family-nurse mode comforting and crying with the
family. Marsha started to clean up the room and body to make
them presentable for viewing. The doctor and I debriefed before
going our separate ways. He went to see other patients and
I went about other charge nurse duties. The shift finally
started to quiet down and I did a silent cheer when I was
able to let Kellie go home early.
At the end of my twelve hours I gave report to the oncoming
charge nurse and left with a smile. I had the weekend off.
About
Matt
Matthew
Nathan Castens got his start in 1994 as a nursing assistant
in intensive care, coronary care, and emergency.˛˛He graduated
from Normandale Community College in Bloomington, Minnesota
in May of 1999 with his Associate’s Degree in Nursing.
Since
January of 2000, he has been on staff as a registered nurse
in the Cardiovascular Intensive Care Unit at North Memorial
Medical Center in Robbinsdale, Minnesota, one of the first
ever units to promote the single-unit stay environment for
open-heart recovery. He also works as a flight nurse for ALS
AeroCare, based in the Twin Cities.
Matt
specializes in the recovery of open heart surgery patients,
trans-myocardial revascularization, and the care of myocardial
infarction, CHF, and pulmonary edema. He is also very familiar
with intra-aortic balloon pumps, dialysis, and continuous
renal replacement therapies.˛˛Matt is a member of the American
Association of Critical Care Nurses.
Matt
is experienced in working with a wide population of patients,
thanks to the availability of experiences in North Memorial's
Trauma/Neuro and Medical/Surgical ICUs. Visit Matt’s
own page at: The
ICU Answer Page! Original Holder of the Patient
Health Education Award Member: Nursing Peer Excellence WebRing
Or go directly to his ICU
Answer Forum...
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