Boi

If you want to read a remarkable story about a little boy with a big problem, read here about Boi. I heard it from one of the nurses that took care of him.

Well, what have we here?

Things have been busy in the ICU but nothing out of the ordinary.

I feel truly sorry for an older patient in the ICU the other day. This person was another nurse's patient, but I started the IV. Even though the patient was very old, he/she was as sharp as a tack. I don't know what his/her H & H was, but he/she was white as a ghost. The patient had a number of bruises on each arm and some petechiae. I asked about it, and the patient said, "Oh, don't worry about it honey; I have lots of those, and they've been around a long time." I started the IV with no problem. This was about 1815, so I didn't know what happened until the next day.

The night RN gave the first unit of blood and sent her LPN to get the next unit. When the LPN returned the RN said, "You need to take it back." The LPN was confused but found out the patient died. Turned out the platelets were only 10,000 mm3. If the patient only had gone to the physician a little earlier.

On Wednesday, I was trying to finish my assessments and help my GN as well (We had 4 patients). A little after 7 one of the LPN's on the Med/Surg floor came back and said, "We are moving a patient back for respiratory failure. His heart rate is 130 to 140, his RR is 40, and I can barely wake him." During the night shift the resp therapist had tried to get the agency nurse to call the doc, but he didn't.

So here they come. This patient was pale, would barely arouse for me with hard stimulation. The AP was 130 to 140, RR 40. Warm and clammy with red cyanosis of the extremities, thready pulse, the whole works. The monitor showed sinus tachy. SPo2 was 85% ( on bipap). SBP was 100's (I can't remember for sure now what the exact VS were). I put the patient in high fowler's position, the resp therapist started bipap at 19/6 and 70% O2. The patient settled down a little except for the heart rate and RR. Breath sounds remained very diminished.

The doctor came and decided to intubate, since the patient was wearing out (no lie). Resp therapist got the vent, I got everything else. The doc had trouble getting the ET tube, so the ER doc did.

There was a big clot partly obstructing the airway. He suctioned that out and was successful.

Vent was set at AC/Vt 800/70%/RR 12/Peep 5. The patient settled down even more. I had to give a lot of drugs to relax the patient. If I remember right I gave a total of 10 mg of Versed, 200 mcg of Fentanyl, 100 mg of Sux. I started the propofol with a 10 ml push and the drip at 35 mcg. That didn't hold at all. I eventually increased it to 65 mcg to keep the patient at a Ramsey's scale of 4. Whew!

Then we found out the patient was a Do Not Resuscitate. The patient didn't code, just had bad pneumonia, and we couldn't just let the patient die. Well, now what. There was no kin that anybody knew of.

We found a written DNR that was only for "Outside the hospital", so we were covered other than the night MD had written a DNR.

Thursday I tapered off the propofol for the trials (no order but that is what we do). When the patient was awake (about 10 minutes later), the Resp Therapist started Cpap to see if the patient could make it on his own (with 15 Peep for pressure support). His doc came in and asked him about the ET tube, "No, I don't want it. Take it out," the patient wrote. But then, "I want to live." Well, this went back and forth for at least 30 minutes. (I couldn't anything else done or help my GN (I'm responsible for her, you know), so another RN from Med/Surg came back to help her). Finally, the ER doc who had put in the ET tube wrote: "Do you want the tube out" and wrote "yes" and "no". "Circle which you want." The patient circled the "Yes". So, I get ready to call the resp therapist to get the tube out, but before I left (the ER doc had already left the room), the patient's doc asked one more time, "Do you want to live?" The patient nodded a "yes" vigorously. So I got an order to sedate and maintain the Ramsey scale at 4, so I bolused the patient with 10 ml of propofol, and the patient was out in seconds.

Meanwhile because of all the confusion, the CNO (used to be called Director of Nurses, but now Chief Nursing Officer) and our risk management RN came over to sort things out. She got on the phone and made lots of phone calls. The risk management RN finally found a relative who lived in town no less. This relavtive would visit weekly, agreed to come in, and help us figure out what the patient really wanted.

On the relative's arrival, I turned off the propofol, and 10 minutes, or so, the patient was awake. The family talked, the patient wrote, and agreed to leave the ET tube in, continue treatment, and be transferred to the care of a pulmonologist near by.

The patient's XRay is AP projection taken on Wednesday in ICU. Pretty bad, huh? I seen them worse of course, but the patient was getting worse, too. Seeing the XRay, a CT was ordered. I was too busy and couldn't leave my GN anyway, so RT bagged the patient through the CT. The CT pictures are pretty yucky. No wonder the patient was having trouble breathing. When I saw those, I knew why I took a lot of time suctioning blood and pus from the ET tube.

So finally the patient was shipped out to the pulmonologist. I hope the patient makes it.

Busy Day

Busy day! I know that a big city ICU has a lot more than we do, but these cases were interesting.

Patient 1 is a severely retarded person who now receives a tube feeding. Jevity is spit up, vomited, or the patient works to get it up all over herself. We need to get this patient off the TPN. I tried ProSoBee and it stayed down. Weird.

Patient 2 came to us in severe, end stage COPD. Tthe first rhythm strip I thought was a-flutter with 2:1 capture. The MD wanted to start Cardizem per protocol, so I bolused the patient with 20mg just after I started the drip at 5mg/h (5ml/h). No result. I increased it to 10mg/h, no result. I increased it to 15mg/h; the rate dropped to 100 for about 15 seconds and then back to 170-180. I rebolused with 25mg with no result. The SBP was in the 120's so I didn't worry about it and watched the monitor while I went about my other work. After a few hours with no result, I thought I would try Morphine 4mg IV, thinking the patient might be anxious. No result after 30 minutes, so I called the MD who was also watching the rhythm in ER (it was his patient); he said to wait a little longer. Finally, everything worked, and you can see the second rhythm strip.

Patient 3 is a chronic smoker, past CABG, insulin dependent diabetic, etc. Those are the XRays. The patient called EMS stating had a hard time breathing, by the time the patient got to ER the patient was in respiratory failure and needed to be intubated. What do you think was the unlying cause?

The patient was awake when he/she came to us. I used propofol for about 35 minutes but decided the patient was cooperative enough that I stopped it, figuring the patient was ready to be extubated. Respiratory therapist checked up on the patient and stated it would be ok to go on pressure support. The patient did well, but would occassionally have apneic periods up to 20 seconds. The vent alarm would wake the patient up. Because of that respiratory thought it best to keep the patient on the vent until the morning; the patient agreed to the plan.

Today they plan to extubate, but I'm not working. I'm sure they will be successful.

Prosthesis Artist

This shows you what a good practitioner of cosmesis can do.

These are from L. Daniel Eaton, B.C.O., I.M.F.T.
Web Site is http://www.ldanieleaton.com/image_testimonials.htm

The BCO stands for Board Certified Ocularist. I'm not sure what the other stands for.

Here are two write-ups of him.

"Daniel Eaton is currently an assistant clinical professor in the department of surgery at the University of Arkansas for Medical Science. He was previously an assistant professor in the department of Otolaryngology, Head and Neck surgery, UAMS.

He received the “Legends” award for cancer research from the American Cancer Society and the recipient of four medical technology and design awards. Eaton is a board certified ocularist and his education includes undergraduate; Arizona State University, graduate; University of Cincinnati, College of Medicine, Hemlock, MI., (biomaterials) and Sahlgren’s Hospital, Gothenberg, Sweden, where he studied Osseointegration under Professor Ingvar Branemark.

At present he is also in the private practice of alloplastic facial reconstruction and is a research and development consultant for ContourMed, Inc.

Eaton is a member of the National Examining Board of Ocularists, the American Society of Ocularists, and the Institutional Animal Use and Care Committee at UAMS, and is a principal for the National Collaborative Melanoma Study. He is a member of the American Association of Medical Sculptors, the International Academy of Oculofacial Prosthetologists, the Society of Illustrators, the Institute of Maxillofacial Technologies , the American Alloplastic Association and Pi Kappa Alpha.

Eaton earned a master’s degree in medical illustration with a minor in human gross anatomy from the University of Cincinnati College of Medicine. He earned his undergraduate degree from Arizona State University . Eaton has obtained more than 250 hours of post-graduate training in gross anatomy, oculofacial prosthetology, elastomer chemistry and maxillofacial osseointegration."

If you a person needing this type of skill, it is available.