I met Mr. Posey for the first time shortly after getting a report about him from the ER nurse. It was the start of a new day for me, for the ER nurse it was the one last thing he had to do before he went home to bed. I got a bunch of facts from him, and then he shuffled out the sliding door and headed home.
I was in the ER to pick up my new patient, and to safely deliver him back up to the unit.
Posey had walked into to the ER about midnight with a complaint of, “An elephant sitting on my chest.” The ER nurse told me that this particular elephant had been parked on him for the better part of the day.
Posey was sitting up on a gurney, and was a large guy, about 325 pounds. As I introduced myself, he started talking to me with a real thick Georgia accent- something I remembered from childhood when visiting my dad’s family. I liked him on speech; it was “like at first sight.” He reminded me of my grandfather – the dead one I didn’t have. (My grandfather had died years ago when I was four, from a massive heart attack, at the age of 47.)
Mr. Posey seemed happy to see me. It might have been that we had one of those mythical bonds on contact, some weird connection that was instant, but solid -- a long-lost, long-term family thing. It might also have been that he had been sitting on a hard gurney for eight hours waiting for something to happen. It might have been that the elephant was no longer sitting on him.
I had seen his admission lab work in the ER and I knew the numbers – they were bad – the CPKMB was well above 20,000. I could see there was a death drill coming in our futures, but it was hard to get my game face on for it. Things were not going to happen in the usual way, I had lost my distance by connecting to him too soon, connecting because he had channeled my grandfather back from the grave.
In my years as a nurse, I had never lost a person who wasn’t supposed to be lost. I had always been able to see the big picture of how it worked, was always able to stand back to help. Distance made it easier for me; I took in the information, and converted it to honest words -- much like a United Nations interpreter.
From the ER, we took a short ride to the elevators and went up to the forth floor, and into the unit. After scooting Posey from the gurney to the bed on a slide board, I plugged the leads for his monitor into the console, and made sure the IV’s were working. As I set the IV’s up on controllers and made sure the oxygen was turned on and the suction machines working, I started my unit orientation talk to him.
Mr. Posey stopped me before I got started. He asked me to tell him what was going to happen to him.
For some reason, I told him the truth. I told him that he would probably die. He seemed to measure both the thing that I told him, and me, at the same time. I told him the exact truth, in straight language, without any mixed message.
My style has always been to give options, to present both sides of things. I was surprised by how direct my answer was to him. I have always felt that it’s not my place to decide life and death issues, that’s for God and the patient to work out. I am more a facilitator, a helper, and a front line grunt sort of guy. What I told him was outside my chain-of-command. I had stepped over the line with Mr. Posey, and I was now committed -- I had become involved.
I was thinking of my grandfather, sitting alone in a backcountry doctor’s office after a long day on the lake fishing, just waiting for an ambulance to take him to the hospital. His pain had started mid-day, but he had been alone in the middle of nowhere. By the time he got to help, there was no help.
And he did it alone. No one should do it alone.
The blood supply to the heart comes from the outside to the inside. With a blockage in an artery, every part of the heart supplied by that artery dies; again, it dies from the inside to the outside.
On the first day after a heart attack - the heart is still deciding how much of it will die- From an initial area of absolute death where the cells breakup and release the poisons of their intra-cellular machinery, the injury creeps out to the nearby and merely damaged tissue and starts to kill this as well. These days we have medicines we can give to keep some of this stuff from happening, but on Mr. Posey’s first day in that long ago time all that could be done involved forms of watching.
During the first 24 hours after a heart attack, the heart- both the good part and the dead part, hold together, mostly because they don’t know any better. The dead part doesn’t contract, or pump, anything so the heart doesn’t push the blood out as well as it did before, but on that first day, the heart itself holds together fairly well. I think it’s like a dead tooth in your mouth- it sort of stays in place out of habit, until a push comes to a shove. Push always comes to shove -- that's life.
The secret thing you fear the most always works its way free and the movements of life have a way of bringing stuck things to the surface. You can’t stay still because if you stop moving, you’re dead – that’s life too.
What you see on the first day is the pump, also known as the heart, not working quite up to snuff. As the pump begins to fail, blood starts backing up into the lungs. You can hear this happening with a stethoscope by listening to the movements of air as they go in and out of the chest. When Mr. Posey would take a deep breath, you could hear a sound like a clump of hair being rolled back and forth in your hands.
This was the first objective sign that his pump was failing -- that a backed up pool of fluid was starting to bathe his lungs and interfere with his breathing. He was becoming juicy, and not in a good way. The lungs are not a good place to store extra fluids – it gets too bubbly. Think drowning.
At this point I could only hear fine crackles of noise from the lower part of the chest, and this was mostly in the lower bases, only heard well when listening from the back.
Using the standardized unit admission orders, I increased his oxygen and gave him a diuretic (Lasix) to help him pee off some of that backed up fluid. I also started a drug through continuous IV drip to help make the heart beat more forcefully (dopamine). I added Nitroglycerin (NTG,) at a constant infusion rate to make the muscles on the venous side of the blood system relax. By relaxing the veins, which drain and pool in an area before the pump, the blood gets more room to back up into – a sort of forebay, or waiting room. Nitroglycerine helps increase the size of the intake part of the pumping system (Preload).
None of the things I was doing would make him better; they just slowed things down for a while and made him more comfortable. They treated the symptoms, not the causes. What I was giving him was comfortable time, quality time – not a small thing, but not really anything I valued at the time.