I went to dialyze patient Brown in ICU 17 this afternoon. Dr. R had told me to maximize the fluid off of the patient, but cut the treatment to three hours, because his fluid overload was so severe, and his phosphorous was so very low. I’d called the ICU, and told the patient’s nurse, Nick, when to expect me. From Nick, I learned that the patient was male, had come in with pneumonia and had alcohol-related cirrhosis and subsequent liver failure.
It’s a common clinical picture, actually. Have seen it 100 times.
I checked in with Nickfirst. He’s a grizzly bear of a man, and from what little I’ve seen of him, a damned good nurse. He gives me the lowdown of the patient’s clinical situation as well as the social story (i.e. family dynamics) in 20 seconds or less, and I always appreciate that.
I wasn’t sure that Bob was male when I saw him at first, as his face was discolored with bruises. This isn’t because anyone had hit him; this is because his liver was no longer making clotting factors. The bruising went down his left arm, and onto his left leg, too. I wonder if he’d fallen at one point. He looked every bit end stage liver failure, with a profoundly round (firm) and distended abdomen, yellow cast to his skin, and very thin, thin arms and legs from the long malnutrition of alcoholism. He was intubated, but not yet on “pressors”, or vasoactive iv drugs. His A-line showed his pressure hovering at a wan 90 systolic, with a sinus pulse in the one-teens. Intravascularly dry, severely edematous in the tissues. And bleeding anywhere a blood cell could leak. I could smell it in the air.
I was there because he hadn’t urinated in a week (shock kidney from the liver failure, and possibly hypotension). I introduced myself to Bob, told him who I was..(eyes opened, but icteric and unfocused)...and as I touched his arm, by way of introduction and reassurance, I gently pressed a finger against his skin. My finger made an indent a half an inch deep. Imagine a half inch right now….that’s deep. It told me most of what I needed to know about the shape his body was in. There was no way in hell I was going to meet Dr. R’s hoped-for goal.
Then I turned my attention to his wife, Carol. I introduced myself, told her what I’d be doing, and what to expect. I told her it was important for us to remove some of the excess fluid in his body, because it was filling up his lungs, and making it impossible for him to breathe on his own. Get the fluid out, and hopefully get the tube out. “Yes, this is our third time with this dialysis. I understand.” I smiled. She’s an old pro, then...or more likely, trying very hard to be a pro because her world is spinning out of control. I shook her hand, and told her I’d set up. She wasn’t chatty as I did so, which was okay with me. She quietly did Sudoku, and gave noncommittal monosyllables as I commented on the weather, and the depth of the snow in the mountains. I let her be, and began my spin.
I started off with a blood prime, meaning that I pull almost a unit of blood (most adult bodies have 5 to 6) out of the body before returning any saline to compensate for the volume loss. I do this whenever I think I am at risk of having to give more fluid to a patient than take it off, which is ultimately harmful to the patient. Most patients roll with this all right. His pressure dropped 20 points. His body didn't like it. It took him 10 minutes to recover.
Nick came in to check, as the alarms went off at the desk. “Need anything?” “Nope, sorry, I blood primed him. He’s a closed circuit now, and I’m hoping it’ll go back up.” He nods, repositions the patient with me, gives a few meds due to the patient, reviews some orders with me.
We’re busy, and we’re also noticing that the pressure is crap, and we’re busy so that Carol is less aware of the fact that Bob’s pressure is crap. Oh, says, Nick, “incidentally”, I got a PICC line placed today, in case we need it. I nod. This means: “Let me know when you want the Levophed. I was prepared for you.” I coulda kissed him. This is wonderful. He knows we need it; he's known for three days that he's taken care of Bob. He knows. We don't diagnose. But we do know, and we prepare for it.
The pressure recovers somewhat. But I'm aggressively pulling fluid out (i.e. pulling water from the pipes), and I fight with Bob’s blood pressure for an hour, having to give back almost every milliliter I’d gained. After an hour, I’d gotten a half a liter. This is pathetic, compared to the goal set by my doc. My doc's goal was to help get him off the ventilator, and that wasn't going to happen with a half a liter an hour.
Bob’s sister arrived at the bedside, and was asking questions. Carol was too weary to notice how often the pressure was too low; Bob’s sister was not. After a full hour of the treatment, I paged Dr. R, to let him know that we were getting nowhere. He asked me to try albumin. Okay, cool. Let’s try some albumin. Nick gets it from the pharmacist for me, as I explain to Carol and the sister what albumin is, and why we think it might help.
Alcoholics have no albumin to speak of. This is because they do not tend to eat. They drink instead. I explain this gently, by saying, “Bob probably had a very poor diet before, (Carol nods) and that, compounded by the fact that his liver isn’t working, is making the amount of protein in his blood very low.” And then I explained that it would effect the amount of fluid I’d be able to take off…big molecules and little molecules. The sister appreciated the explanation “in English” (as she said), but Carol was in sleep-deprived numbness. She nodded when her sister-in-law nodded, and let someone else ask all the questions.
The sister asks about how the machine works, and I tell her. Dialysis is easy...it's salts and water. People can understand saltwater. And it works with the heart, which is also easy, because that's just electricity and plumbing. I mean, obviously, an electrophysiologist disagrees, and s/he is right....cardiac automaticity and periodicity is ridiculously complicated. If you're interested in those groovy details. I love pathophys...and I to love the complex chemistry behind dialysis. Bob's sister doesn't care. But she gets it when I tell her I'm squeezin out saltwater. And that I have a filter (to which I point) and this is where the blood is cleaned before I pump it back into her brother. And she appreciates understanding.
Before I finished getting the albumin into Bob, his pressure dropped to 69/32. Nick was at the bedside with me (because it looked dicey well before that), and I said, “Nick? Do you have an intensivist handy?” “Yup, whatchoo want?” “Um. I just suspect it might be a good plan to tell him we’re havin trouble getting fluid off.” “Yup, me too.” Exit Nick, for a few minutes.
I explained to the two women that the physician might want to consider a medication to keep up Bob’s pressure, since it just wasn’t cooperating. Because they wanted to know what to DO, if the fluid won't come off. I said the medication was ‘a big gun’, but that it might help him. It was serious, but it was just a tool, like everything else. The sister-in-law loitered some, but left, because Carol told her that "Bob is supposed to rest today."
Nick brought in a line already primed with Levophed. (Did I mention that this guy is an awesome nurse?) As he hung it, he explained what he was doing to Carol, too. She nodded. Repetition isn’t done to annoy when your family is in this state; it’s because they don’t really hear what you’re saying. Nick did warn her that the good thing about it is we’d be able to get fluid off. The downside is that there was a risk that it would be difficult to then wean Bob off the high-octane medication. She nodded again. And went back to Sudoko. Or numbers on a page.
The good news (sort of) is that I was, from there on out, able to pull fluid! (I guess this was a win, right?)....
Carol and I sat mostly quietly for another hour. She had her Sudoku, I had an eggplant-colored ball of yarn I was crocheting into an afghan. Sometimes she would call someone, and talk about Bob, and this "blood pressure medication...he's on the dialysis now...he's still on that breathing machine...he doesn't look good today....I wonder if he's in pain, because he looks so uncomfortable right now...." Interspersed with more quiet number puzzles and crochet loops.
The intensivist came in to see Carol. I was a little fly, stuck to the wall, in a small chair in the corner. A dialysis nurse isn’t supposed to go far when s/he is dialyzing, and I tend to sit quietly in a corner and read. Today, I made eggplant-colored loops, 150 to a row. I am stuck in the corner as this happens:
Doc was gracious, and kind. He was also truthful, which is my favorite kind of doc. He told her that the prognosis was very poor. He said, “He has several organs that aren’t working right now, we say they have ‘failed’. His kidneys have not made urine in a week, his blood pressure is too low, he’s unable to breathe on his own, and his liver has severe damage from cirrhosis. We can put him on the ventilator to support his lungs. We now have him on medication to support his heart. We are doing the dialysis for the kidneys. But the liver…. Transplant is not an option with a history of alcohol abuse, and transplant is the only thing we know how to do for the liver. We cannot do anything about his liver. He is in very serious condition, and we are not seeing improvement. We are seeing a gradual decline. I feel his prognosis is very poor at this time.”
Carol was standing, and nodding. She was hearing, and part of her was understanding. “I understand.” She was calm (sort of) but, “Nobody had told me yet that this was ‘end-stage’” She nodded. Shuffled her feet.
In short, no doc had actually said yet that Bob was going to die. She suspected. She said she’s talked about it with her family, what they would do, what Bob really wants. But nobody’d SAID it to her yet. She was waiting, fearing, to hear it. And now she’d heard it.
And this is why I have profound respect for intensivists. Because every one I have known has had to deliver this news to someone who deeply loves their patient, this person lying in the bed. And because intensivists are THERE at the ICU bedside, they see this suffering, and they understand that when it is time…it is so important for them to be honest and say that it is time. And the intensivists I've worked with have been honest and I think that takes courage.
The doc said, “I’m very sorry to have to deliver such bad news.” She nodded. She said Bob never wanted this much STUFF (gesturing to the entire room). This is not how he wants to live; they have a living will that is very clear. “He doesn’t want all this,” said Carol, “I’ve talked to the whole family and we all agree that if he isn’t going to get better, he doesn’t want this.” She wobbled. He pretended not to notice. I made eggplant loops and tried not to breathe loudly in the corner.
The doc said gently, “What we can do, then, is maybe wait a day or two to see if we see any improvement. To be honest, I do not expect any, but no doctor can tell you for sure what will happen. If he does not want us to do this, we can stop this. Why don’t we give it a day or two and then make that decision?” “Okay…..How long?” “Maybe we could re-evaluate, say, Sunday? Will you be here Sunday?” “I will be here Sunday…..I will be with him. I will be here. Yes. I can. I can bring the family Sunday, too. Yes." She nods more.
The doc nods, too. “I am sorry to deliver such bad news.” She thanks him. Nods. He nods. He makes a quiet exit. She turns to the window, which is dark because it is evening. I can see her reflection in it quite clearly. She holds her hands over her face, with her index fingers in the corners of her eyes. She is very still. I think I hear the word, “Sunday,” a whisper.
I stand up and walk softly, in my rubber-soled shoes, up to Carol. I touch her left shoulder, so as not to startle her. And then I wrap my arms around her shoulders and put my ear to her shoulder and squeeze.
She shivers, and then a sound comes out, a little like an infant’s burp. And then there’s the sob…...this...SOB, this reverse gulp of air....less a sound than a shockwave from a mushroom cloud. Before it becomes red or grey, when it's just this visual disruption thing. Not heard, so much as felt , down in the belly, right in the gut...and it feels like it has hit every bystander within 10 miles and made them wobble and gasp for air.
My eyes sting with saltwater and I hang on tight so that her molecules do not fly apart.