Saturday, February 17, 2007

Liver failure: prelude to 'Code White'

You need to read this post to understand the one I'll be writing down next. Because, now that I'm pulling my thoughts together, there are two big things I learned about as a nurse this week. One is a few things about clinical pathophys and presentation of liver failure. The other is a few things about how nurses treat and respond to the crisis of liver failure, and in this case fulminant liver failure.

Liver failure is a bad way to go. Most nurses can tell you there are better ways to go than others, and liver failure is not a good one. If you're considering alcoholism as a life choice, please reconsider. Massive MI is a better way to go, but the problem with that one is that in lathering up those arteries, you might just end up with the long suffering of CHF instead. Also, do NOT overdose on tylenol, as this leads to liver failure as well. Use condoms, as you do not want Hep B or Hep C. Wash your hands, as you do not want Hep A. If you use IV street drugs, (not a big recommendation for a host of other reasons), for god's sake, autoclave.

Kim from Emergiblog is an ED RN, and she rocks, as does her blog. Months ago, she did a gutwrenching post, and it's beautiful and has stuck with me since. Here it is.

Some patients seem to hit you on an emotional level, as Kim's did. Some patients interest you clinically, as this one did. Nurses do not tend to be the people in your health care world who forget ever that you're a person. I touched this woman's forehead to see her eyes, and I did so gently because this woman happened to be somebody's Mom, somebody's wife. But as a clinician, I was interested in the machine of human beings working their asses off to save her life. I was interested in what was going on with her body. I was interested in who did what, what roles functioned to do this thing to keep her alive.

This is why this is the first post I'm gonna label "learning ICU." Not because I haven't been for the past 6 weeks, but this is the first time I might have learned some vocabulary words to tell you about critical care nursing.

For non-clinical people:
You know that alcohol abuse and viral hepatitus can crash your liver. You might not know what your liver actually does for you. I mean to say that you know these things are bad, but you don't have a specific picture of why, exactly. Something to do with being yellow, probably.

* Your liver filters broken blood cells, bacteria and nitrogen out of your blood. Let us consider the example of "laughing gas", which is nitrous oxide. What happens when there's too much nitrogen (which is actually in the form of ammonia) in your blood? In small doses, you may feel silly. In toxic amounts, you're beyond crazy and you're in a coma.

* Your liver gets rid of this gunk called bilirubin out of your body. Bilirubin is what makes the skin yellow in people with hepatitis and newborn babies, whose livers learn after they're born to break down the bilirubin. Most babies are born a little jaundiced and it clears in a matter of 2 days. I had hepatitis in 1990, because the mono...a virus called Epstein-Barr, overloaded my liver. I was yellow and felt like hell for 6 months.

* Your liver metabolizes drugs, vitamins and hormones...meaning it breaks them into substances your body can use. Without that ability, your cells aren't getting fed nutrition, and drugs that your nurse gives you to do important things like regulate your blood pressure or heart rate or whatever, are not as effective.

* Your liver helps regulate blood glucose via glycogen stores...glucose = "cell food". It also metabolizes fats. A double-whammy of nutritional deficiency.

* Your liver makes certain proteins, one of which is called albumin, others relate to blood clotting called fibrinogen and prothrombin. Let's start with clotting factors...that's easy. If your plasma, the goo your red blood cells float in, does not have clotting factors, you don't clot. Ergo, you bleed. The less factor and fibrinogen in the blood, the more bleeding. You can see where this is going.

* Albumin is a happy little molecule that transports hormones around your body. It's bigger function, however, comes from the fact that it's big. I want you to go for a moment back to high school biology and chemistry and we're gonna talk about osmosis. Big molecules act like sponges and draw water to them. Wikipedia has a wonderfully egghead explanation. But what I need you to know is that big molecules suck water closer until there's stability between say, what's inside your veins and what's across the membrane of the vessel wall.

Again, with the what does this mean thing? If you don't have albumin, you leak. You leak abundantly. Your blood vessels shrivel up from losing blood volume and you lose blood pressure itself and your body swells up with fluid because all the water IN your body isn't usable to you. You swell with so many pounds of useless fluid that I can make a thumbprint an inch fucking deep into your foot. Your skin leaks clearish-yellowy fluid from any cracks of incisions made, such as IV sites, or anywhere your skin may have been broken.

You are a giGANTic sack of fluid-filled skin oozing your yellow self everywhere, beyond cognizance because of the nitrogen or ability to breathe on your own because of the metabolic acidosis. Your kidneys are dead because your kidneys require blood pressure. Then there's that other small detail of not having any blood pressure, so your heart is gasping for something to do in the time it has before your blood pH and the lack of usable potassium stops it dead. You're probably getting IV lactulose, which is a medication designed to give you constant bowel movements because that gets rid of some of the nitrogen. Oh, and there's the bleeding in addition to the oozing and the shitting. And the most likely place you'lll bleed? Your GI tract. What blood you have, since it can't go through the liver anymore, rerouts often through the veins in the bottom part of your esophagus. These are called esophageal varices. Your GI tract? Big long tube from your mouth to your ass and so you're shitting copiously, and now you're bleeding copiously out of your ass, too.

Fortunately, at this point, you are probably beyond awareness of any of this.

The unfortunate part is that your family members who love you might be watching.


This is a PERSON I'm talking about.

This is a PERSON.



I know you're not wondering now why I had to write this to get it out.

I'm so glad I lost the belief that god/dess/GiantTurtle is responsible for anything that happens anymore. Because I'd be mad if I did.

Instead, I am staring at a gaping hole of entropic causality. I don't feel better about it than you do, probably, but I am not angry. I believe 'existential horror' covers it. There can only be two outcomes of existential horror. Sartre found it in a bullet. I think the only way out is compassion. I'm certainly not the first to draw that conclusion. Taking that complete rainbow in the mist and giving it away as fast and fully and completely as you are humanly able. And that's why there's a part two to this story.

Something I want you to know, too. Lest you are one of those assholes who think that alcoholics deserve this fate, I will tell you that this patient was not in hepatic failure because of alcohol. Nor was it viral. There was not a single lifestyle predisposing factor that caused her liver to die.

Nobody deserves what that woman got.


Kim said...

Well you are the first person I've ever met who can take pathophysiology and break it down into lay-person understanding!

Liver failure sucks. No one deserves it. Ever.

Amy said...

Can I just make the comment that for relatives of people who are dying of liver failure, and are scared what will happen, this article is extremely upsetting and distressing.

I'm currently losing my Grandma from Pancreatic cancer that has metastasised to her liver, and I was seeking reassurance that she would have a good death, and you've made me more scared and anxious than ever.

Darren said...

This article regarding Liver failure and the prelude to Code White is very interesting and useful, the liver failure issue can affect your sexual activity, and this not only happen to older people as I used to believed, young people can also be affected so you may need to buy generic viagra to help yourself on those situations. Thanks for sharing and have a nice day.

frieda said...

For this relative of someone dying of liver failure, this article was refreshingly honest and not at all as scary as watching it happen without information. Thank you.

Rowena Quilts'n Sew On said...

One of my brothers is extremely ill(dying)from liver failure due to hepatitis c and I also have this shitty virus. Thankyou for your ability to explain in lay terms what is happening to my brother, he and his wife are both RN's so they know what's going on, but I did not fully understand. I find ignorance scary, knowledge brings this case very unpleasant but thank you.

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