Thursday, May 20, 2010

Something different today

I finished the first draft of book length memoir yesterday. It’s more than 50k words, and is printed and sitting on my kitchen counter.

I celebrated by going to Pollo Loco and having a dinner of grilled chicken, then stopping by Walgreen’s and buying a small box of Oreo cookies.

I ate the cookies, and went to bed early. 

Today I cut my hair, washed my clothes and got the oil changed in my car.

Who knows what will happen tomorrow.

Wednesday, May 19, 2010

Deadman, Chapter 25

Chapter 25

         I returned to Posey’s room and thanked the nurse who had been covering for me while I was out. She said, “nothing happened,” but I would have been surprised if she had actually done more than listen for the alarms.
         In the unit, we took breaks when we could – our relief was usually a nurse with nearby patients. Breaks were never long, the nurses that relieved us were just as busy and we were, and watching an additional couple of critical patients was sketchy at best. The charge nurse should have been out of care (without patients,) and available to give us breaks, but budget cuts had ended that practice earlier in my career.
         I changed out Posey’s linen again. It got less lumpy, and I satisfied a need for fetish. I looked up at the monitor and notice some changes in the shape of his hearts rhythm. I poked my head out of the room and asked the ward secretary to order an EKG for now. (I requested it, “stat,” but feel the word is overused, and am somewhat embarrassed to admit I even used it back then.)
         The EKG technician poked her head out of the room next to mine when she heard my request and looked at me, and then pushed her machine over to Posey’s room.
         The EKG showed that Posey was extending his heart attack.
         A 12-lead EKG is read in sections. Each section consists of three leads, and they follow the heart from front to back and left to right, showing what’s happening at each specific area of the heart at the time the EKG is done. A heart attack may effect the anterior portion of the heart – this would show up in the V3-V6 leads. A heart attack may damage the inferior side of the heart, and this would show up in leads Avl, V1 and V2. By knowing the leads you are looking at, you can see the damage that’s being done to which part of the heart.
         Posey had been admitted with a large anterior infarct. The EKG’s done up until this point all showed inverted T waves in the anterior leads. This was what was expected – after the death of an area of the heart, the T waves turned upside down. This was seen in Posey’s V3-V6 leads, and was consistent with all the EKG’s he’d had since being admitted to the unit.
         The new EKG showed ST elevations in the inferior leads and also in the lateral leads. The ST elevations were present in all 6 of the leads adjacent to the anterior ones, but the elevations were higher and more pronounced in the leads directly closest to the anterior part of the heart.
         ST elevations are an indication of oxygen starvation – ischemia – The areas of the heart next to the one that had died three days ago were now dying. If Posey had been awake, he would have been having acute chest pain –probably much like the pain that had brought him into the ER. Since he was unresponsive, the EKG was the only symptom to indicate what was happening – that he was having another heart attack. Because it was occurring next to the original attack, the term for it was ‘extending’ instead of ‘new’ -- much like we call it an aftershock for an earthquake that happens on the heels of a larger earthquake.
The EKG indicated that the rest of his heart was dying.
         I thought, “shit,” as I walked out to the nursing station. When I got there, I saw Dr. S sitting at the station and reviewing Posey’s chart. I told him that he was too late, that Posey was extending his heart attack. Dr. S looked at me and said, “let’s go then,” and picked up the phone next to him and called the OR. When someone on the other end picked up, he told them to, “be ready, I’m on my way with him,” and hung up.
         With that notification, we were now officially on Dr. S time  --a time of masterful brevity and dervish action. We both went to Posey’s room, and with the charge nurse, a respiratory technician, and a couple of additional shanghaied stragglers he’d rounded up on the way, we took apart the machines, placed the important things we needed for monitoring on portable monitors and headed out the door. It took less than five minutes to undo my days of work.
         I asked him if he needed a consent signed by Mrs. Posey and he said he had one, though how he had gotten it in the ten minutes I’d been away from her I didn’t know. We careened down the hall, him pushing, and me dragging the balloon pump machine behind him. The respiratory technician was bagging Posey with portable oxygen, and the shanghaied stragglers were trying to keep everything on or attached to the bed as we raced to the OR.
         When we reached the double doors that opened into the OR, a hall monitor stopped us – all of us were unclean, and access was forbidden. As the OR nurse shunted us off to the changing rooms, Dr. S pointed to me and said, “I need him,” and she let me pass, balloon pump and all, after slowing me down long enough to put paper booties on my feet, and to hand me a mask to put on before I traveled further.
         In the OR room: Posey’s bed was pushed to a padded metal table centered in a large tiled room -- even the walls were tiled. A nurse pulled one of the draw sheets underneath him up and to one side and a roller board was placed under it – then Posey was yanked to the table and the board was removed.
         Dr. S grabbed a squeeze bottle of dark brown povadine solution and, like a backyard grill master preparing his charcoal, spewed the solution in jerks across Posey’s chest, then wiped most of it off with a clean towel. He took a scalpel and slashed deeply into the midline of the chest, tracing the outline of the sternum, dipping the blade down to the bone of it. He picked up a medical version of a combination jig-saw/skill saw, turned it on (if it had a pull-start, I would have fainted) and cut Posey’s sternum lengthwise, and completely, into two long pieces. Grabbing the two-piece retractor set, that was connected together after being placed on each side of the chest to form a spreader – He cranked the chest open with a ratchet wide enough to set a dinner plate on, or four big and active fists.
         With the chest open, and exposed by the deep cut he had made, Dr. S slashed a line across the pericardial sack and opened it up, then cutting it back to the edges of the opening and dropping the skin of it into a basin offered by the scrub nurse. The heart now exposed, he stuck his left hand in to do internal cardiac massage and to get a feel for what he was going to have to work with.
         From the time Posey hit the table, all of this took longer for me to write than it took for him to do. As Dr. S worked, the rest of the room was frantic with semi-controlled movement as well. It was like structured chaos in the room, there were patterns but they were complicated and hard to differentiate from the random.
         I found my tubing, and the wall outlet, and restarted the balloon pump. Two scrub nurses set up large flat tables on either side of Posey, and laid out instruments and tools, the perfusionist brought in his by-pass machine and continued the process of setting it up, the anesthesiologist gave Posey injections of narcotics to take him even more under and out, and running around like a crazy person, the circulating nurse circulated and made sure everyone had what they needed to do what they needed to do.
         This was my first time in the OR since I’d left it years earlier (after my short career as an orderly.) I recognized the pace of it, but still was just getting impressionistic snap shots of what was actually going on around me. I could break down the generalities of things – He does this with that, the next step is, -- but not the skilled parts of the action – the special tools, the specific sutures to be used, the learned order of events trained over time. But the pace I understood – it was fast.
         Dr. S continued massaging the heart with one hand until Dr. R arrived, cleaned and scrubbed, from the anteroom, and took over the massaging. S then left to get properly scrubbed and gowned for the procedure.
         The heart uses a tremendous amount of energy – it has to contract 80 times a minute, every day, for a lifetime. The heart is supplied the oxygen it uses for the energy by arteries that run across it and around it. The arteries get the oxygen through the blood that comes through two openings in the aorta, just above where the aortic valve opens.
         One opening goes to the right side of the heart – the right coronary artery (RCA). It supplies a large area, but since it’s mostly for the low requirements of the right side, it’s sort of a backwater for concerns and attention.
         The other opening is for the left main artery – this is a short fat tube that almost immediately branches into two other arteries – the left anterior descending artery (LAD), and the left circumflex artery (LCX.) These are the biggies for heart flow.
(People truly are different, and sometimes the RCA is the major artery, and sometimes they are born without parts of the arteries—and sometimes they have extra arteries. It’s hard to know for sure until you look.)
         A heart attack happens when a clot obstructs one of these arteries, or the one of the arteries gets too narrow to allow blood to flow past it. By-pass surgery is when you take a vein and attach it to an area where the blood still flows – above the obstruction, and then pass the vein over the area that’s blocked, and then attach the other end of the vein to an area that doesn’t have a blockage – somewhere below the obstruction.
         To do the bypass you need to stop the heart in order to tie the knots -- the hair width sutures, the dozens of sutures – on both ends --one end of the vein to the artery, and then the other to the other end.
I’m talking very small sutures that are connecting a high-pressure tube to an active pump. It’s harder than it sounds, no matter how hard you think it sounds.
When you stop the heart, you need to continue to supply blood to the rest of the body, so you by-pass the system with a machine that pumps blood for heart while it’s in the shop. A perfusionist runs this machine, which is large and bulky and looks like sometime on the ban list for exporting to unfavored nations. The machine takes on the role of the lungs – it adds oxygen to the blood as it bypasses the heart.
         When Dr. S returned to the room, he took the large cannula’s offered by the perfusionist and stuck one in the arterial side – in the aorta above the heart, and the other in the vena cava, below the right side of the heart. When the perfusionist started the machine, the blood started to flow around the body, but minus the action of the heart. (I had stopped the balloon pump when the perfusionist handed Dr. S. the cannulas.)
         Dr. S stilled the beating heart with an iced solution of saline and minerals – to cool it down and to stop it from contracting. When the heart stopped moving, he started digging though the yellow fat that covered the heart to find the first artery that he wanted to bypass. He started his digging around the mushy part – the dark blue of damaged areas, places obviously dead and necrotic, and the areas right next to them.
         The veins for the bypass were being removed from the legs. As Dr. S worked the top half, a elderly old-timer surgeon made long incisions to the inner parts of the thighs and removed pieces of the saphenous veins – placing them in a basin of salt water for Dr. S to use as tubing for the bypass.
Not technically difficult, harvesting the veins paid well, and the cardiac surgeons gave the job to old mentors and other potentially useful doctors out of tradition, and as a sort of homage to the early adopters of thoracic surgery – those old doctors who, when faced with unemployment due to a cure for tuberculosis, found another outlet for their skills – open heart surgery.
         Dr. S, with Dr. R holding it in place, took one end of the supplied vein, and using a microscope placed over the retracted opening of the chest, starting tying the vein to the artery. Each connection took dozens of micro sutures, but each took Dr. S only ten minutes to tie them together – he was very fast and accurate.
Having identified four blockages that he wanted to go around with the new veins he had, it took less than an hour for him to find and then finish the work on them. The only words I heard him say during this hour, that consisted of more than three consecutive syllables:
         “This is like sewing wet tissue paper together.”
         When finish with the last suture, Dr. S took two paddles from the tray of instruments next to him and had the circulating nurse connect them to a defibrillator. Placing one on each side of the heart, he shocked it. He shocked it again, and then he shocked it again. After the last shock, the heart started beating, weakly and without force—it sort of quivered with regularity.
Many times after heart surgery, the heart acts like it’s stunned for a while, like a fish kept too long out of water, so we all stood there and waited for the heart to come to its senses and gain enough strength to rejoin the body.
         We waited.
         Once, when unemployed, I’d scheduled a job interview near my house for noon. At ten, I started watching a movie about an alcoholic, planning to watch only until he saw the light and got into recovery. Fifteen minutes before my interview, he was still drinking. Five minutes before my interview, he died -- drunk and alone, with his body resting near a dumpster. He never got it, and I missed my appointment. It was that kind of waiting.
         After a half hour, most of the people in the room had drifted off. Dr. S asked the perfusionist to turn off the bypass machine and removed the cannulas from Posey. The heart continued to beat, but without enough force to give a blood pressure to the rest of the body.
Dr. S removed the sutures attaching the balloon pump to Posey’s groin, and pulled the balloon out of the artery. He asked me to hold pressure at the site, which I did.
The scrub nurse that had remained in the room then pushed the two large trays of instruments away from her, and laid out a few items on a smaller tray and scooted it nest to the table where Posey lay, then took the rest of her equipment and left.
         After an hour, Posey’s heart stopped. Dr. S did not try to restart it. Taking wires from the small tray, he attached them to a needle holder and pushed the wires through Posey’s sternum to tie the bones back together. When he finished, he asked me to clean up, and left the room.
         In the end, I did the things that nurses are always left to do.  I removed all of the tubes and lines that were attached to him. I held pressure on the places that leaked, until they didn’t leak. I got warm water and towels, and used them to wash his body until it was clean again.  I walked out of the room and got a gurney, returned and rolled him onto it, and then covered him with a clean white sheet.
         I felt no goodbye, and sensed nothing from him. I left the room with only my memory, and only a prayer that the memory would be good enough.        



Tuesday, May 18, 2010

Deadman, Chapter 24

Chapter 24

         There was a lull at the change of shift, as if we had decided as a group to pause and take a deep breath. The nurse I had relieved four hours earlier finally had time to give me report on Posey, though it was little and late, I appreciated the effort. Her night had ended brutally, with the death of a youngish open-heart patient, and her report was more about her than Posey.
         To talk about the things in your head is to set them free. But as a nurse, it wasn’t that easy. Spending the day juggling facts and feelings to construct a reality of absolute control was not something that just fell out of you at the end of your shift, and the subject matter of the actual work itself was not a thing to casually bring up at home with the loved ones. Shit, piss, blood, pus, and death were not things we replied with when someone asked how are day went.
         Some of the devils in our heads came out in work, through black humor and cynical jokes, and sometimes we got together as a group outside of work and drank a lot. As a rule, most of us did not talk enough. The more tightly the feelings in our heads were bound and wound by the science of facts, the harder it was to get them out by talking – it took longer because the work itself made the binding of feelings necessary to our beliefs.
         Talking got the inside out, but without a lot of talking, the inside things couldn’t get unwrapped enough to become available for the senses to sort through. Without enough talk, you just got the excuses, justifications and cover-ups. You got bundles of feelings spewed out in short bursts, all mixed up with motivations, directions and other crap. Only lots of talk allowed the time necessary to find the nuggets of feeling that accidentally got uncovered with the catharsis of throwing words about work up and out, and only time allowed some of the real stuff to stick.
         You’ve got to talk and get it out or it will start to kill the part of you that you needed to connect. But few want to listen, if you bring up digging out someone’s impacted bowel with your hands clinches the hard stool as you removed it, or dealing with a mother who has lost her daughter -- others would just flinch from the sound of you, and roll away as if they had wheels instead of feet.
         Nursing is not normal work, the hours are strange and the work consists of doing things that repel – things that you spend long childhoods learning to avoid -- like hot flames, or men wearing pinky rings. To be a nurse is to always have a head full of incongruities – you do things that you know are abnormal and wrong and you are exposed to the rawness without being allowed to show the weight of it as you walk around. When you try to shed it, you find yourself surrounded by walls without doors, peopled by creatures that most resemble rubbery obstructions from a bumper pool table. Every attempt to connect just bounces you across the table and into something padded but hard.
         It’s hard to get enough out in appropriate ways – The job is too much, no one is built with enough outlet valves to drain it, and few have enough capacity to store it – even stuffed real tight and shoved down deep, it leaks out.
         For many of us, drugs help with the stuffing. It was hard to work around drugs everyday, and to see them help others deal with catastrophes and not think it might work for you. They didn’t fix anything, but functioned like a pile of bricks on a stack of newspapers – they weighed us down and kept the wind from blowing us away, as long as we were careful and got the dosage right.
Drugs had side effects, and cost the ones who used them maybe more than they could afford to lose, but we were not cows, and were not designed to carry the weight we were asked to carry without end, or, at the least, occasional relief.
I’d been avoiding Mrs. Posey since I’d come in that morning. I wasn’t sure what to say to her, and didn’t have it in me to face her needs. I took the lull in the unit to walk out to the waiting room to find her.
I found her on the phone talking to her kids. She looked old, her hair was pasted to her forehead, and she was without makeup -- she looked like an elderly woman waiting for death to catch up to her. As I walked over to her, she said a short goodbye to the phone and hung up, then clasped her hands together on her lap. I sat next to her on a plastic chair and said nothing.
After a pause, she said that she had talked to both Dr. Lee and Dr. Cat earlier, and that she had not been encouraged by either. As she said this to me, I sat still, but my head was racing. There was defeat in her voice, and though the words were not clear to me, the substance in the tone of it was.
As a nurse you develop a relationship with the family – sometimes it’s the only real contact you have with your patient – since many times they’re obtunded and beyond caring by the time they get to the unit. Part of the relationship is about communicating and the other part is about guiding.
Back then, to most people, hospitals were like great and old Catholic cathedrals run by priests that faced away from them (towards god) and read the magical words of redemption in Latin from a book transcribed from another dead language (Greek.) The job of the nurse was to serve as a knowledgeable, but not too stuffy, parish priest as you explained the words and gestures, and, in general, act as a translator for the gods and rituals of medicine.
The relationships you developed as a nurse with patients and their families started from interpreting what was going on around them and, because of this, the initial conversations were usually and necessarily one-sided. It’s almost impossible to imagine either being critically ill, or having a loved one hospitalized and dying --usually it’s something that you get thrown into, and not a choice done after reflection and careful planning.
And once you are in the hospital, you are in a machine of complicated parts and unpronounceable words – all new to you and beyond any stability of understanding – you really are in a cathedral of death, as practice by people without a religion that gives you comfort. And the only faith you can see and touch comes from the nurse and the way that nurse carries herself as she preached to you her understanding.
Decoding the mystery of medicine was the basis of all relationships you developed in the hospital. But back then, it wasn’t enough to just explain, you also had to guide. As a nurse, you were expected to give direction, and to voice best choices to your patients. There was no marketplace of ideas for patients to choose from – they’d never been in this market before, and the ideas that were being sold were all written in a language they didn’t understand. There was no google to search, or simple answers to be found in magazines – medicine was top down, patriarchal, and very user-unfriendly. Patients didn’t even understand that, for them, doctor’s orders were merely suggestions, without any rule or law to command enforcement or penalty for rejecting them.
Our job was to guide our patients in their choice of treatments, to weigh and measure them, and their capacities, and to then judge what was best for them. When finished with our evaluation we were then to tell them what to do in a way that allowed them to think they were in control and making the decision. Our job was to give to the patients and family the illusion of free will, while actually practicing a limited form of predestination.
To be a good nurse you had to do these two things: simplify the complex and guide decisions. Nurses care for the sick – and this is how we define care.
Sitting in the waiting room with Mrs. Posey, I was of two minds – each with a though and each with a plan.
The mind that had gotten me through life up to this point wanted to tell her the truth – that her husband was dead, and that it was now time to say goodbye. The thought was simple, and it came complete with a plan to soften the words and make them more gentle than simple.
The other mind wanted to do something – anything. The plan was even simpler than the thought – by-pass surgery.
I made a decision, and began to guide Mrs. Posey towards it.
It’s our minds that we use to create the shell of ourselves that we show to others. Off this shell, we project what we want others to see, and then call it by our given name. Driven by fears, and the ambitions of fear, we hide what’s inside us, afraid of what it might do if allowed to play in the light. We make wrong choices based on want, and do what we know is wrong based on fearful wishes -- by blinding the sight of what we know is true on the inside.
A shell works both ways, and it’s hard to know what a man will do until he’s facing a choice he doesn’t want to make, with consequences he doesn’t want to live with. Heroic poetry is written for the man who chooses well, and tragedies about the ones who don’t.
Most of us create our outside as the vision of a Mother Theresa nursing kittens -- with both kindness and breast. But underneath this thin eggshell veneer of the civilized, is the truth -- we are all just Nazis waiting for the train to show up. As the Jews know, but seldom talk about, the best of them did not survive the holocaust – those without the skins of an animal to drape around their insides  – those with pity, compassion and decency, were all left to melt in hot furnaces, leaving only ash for the wind to scatter.
We of the western mind do much of this with death. We not only don’t value what it brings to the table – we penalize it and make it sit in a corner facing the wall. We apply to it the same standards of adversarial debate that we apply to the law – on one side we put medicine, on the other death, then we only allow medicine side to argue – and shackle death to a chair with a gag in its mouth and a bag on its head. We do this in apparent blindness to the fact that death always wins – all of us die and are no more. We can delay things, but honestly, the Governor is never going to pick up the phone and call.
Other cultures embrace death, feeling that the lack of it would be like the lack of clouds in the sky. Others say that only by coming to grips with the fact that we are doomed to death allows us to appreciate life – to live is to die, they say.
But as comfortable as I am with this knowledge, when the last breath comes to me, no matter how much I’ve prepared for it or how much I understand about it, I think my last request will be for more.
In the end, my decision to Mrs. Posey was driven by this thought. Not reasonable, the decision was selfish and motivated by fear -- I chose to do something because I was afraid not too.
What I was afraid of is what everyone is afraid of – death. To leave what I am for oblivion seems scary – where do I go, if anywhere? What awaits me at the other end? How will I be remembered?    And in the end --what mark have I left to find my way back?
I take some comfort in what Carl Jung said, “It’s not a question of where do you go when you die. The real question is: Where were you before you were born?”
I’ve come to believe over the years in a spark. In myself there is an irreducible piece of me that has transcended the events and the years that have passed in me. It is the piece that has remained the same and constant, the thing underneath all things that I call myself. Whatever else I am – a father, a son or a piece of meat that breathes, I’m this -- and I don’t think this can die.
I chose to guide Mrs. Posey to by-pass surgery for her husband. I did it for the wrong reason, though only my insides were aware of the motivations at the time. I believed in a small part of my head that there was a chance of it working, and then I built up that small part until it was big enough, and ran with it.
I told Mrs. Posy that it was a good thing that Dr. at refused to do the surgery, that it was a big and complicated procedure, and that Dr. Cat might not have been technically capable of doing it. I told her than another cardiac surgeon – one that I highly recommended, was on his way, “as we speak” to evaluate her husband, and that I would do what I could to make sure he was the one to do it.
Feeling better, in the way that a hard decision put off for later felt better, I left Mrs. Posey, walked down the hallway and returned to her husbands room.



Monday, May 17, 2010

Deadman, Chapter 23

Chapter 23

         As people streamed into the room to help with the code, Posey’s heart monitor changed from ventricular tachycardia to ventricular fibrillation. The monitor bonged more rapidly with the change in rhythm, and the numbers began to flash red with each bong of the alarm – to show to the senses an elevated urgency.
         Ventricular tachycardia was a bad rhythm, but at least it was organized and trying – ventricular fibrillation was just a bag of wormy muscles just trying to get out of the bag to run amuck alone and without a plan.
         The treatment for both arrhythmias were the same – shock and awe, better living through electricity.
         Just as the heart is divided left and right, it’s divided up and down as well. The upper chambers of the heart are the atria’s, the waiting rooms. Low pressure, and fairly thin walled (left thicker than right) they are the areas where the blood pools before getting passively sucked, through the opening and closing of valves, into the ventricles -- which then do the actually work of pumping – or contracting.
The sino-atrial node is where the pathways that conduct the electricity that’s used to initiate the contraction are located – it’s between the upper and lower chambers. When the impulses that go up get irritated or blocked, you get atrial arrhythmias -- when the pathways that go down get irritated or blocked, you get ventricular arrhythmias. They are both caused by the same kind of problem, but the consequences are much different.
If you lose the function of the top chambers of the heart – the atria – you lose up to 20% out the output. If you lose the bottom chambers, you die.
Ventricular tachycardia after a heart attack usually happens because of irritability – the leaks of acids and other poisons from the dead areas of the heart cause inflammation and irritability, making the trigger threshold for ventricular tachycardia low.
Imagine the heart as an organized group of drug addicts – all in acute withdrawal. The addicts are all lined up for a race, and all scheduled to start when the green flag starts. The prize for winning the race is a bag of dope.
It’s that kind of irritability – and individual muscles either irritated by leakage or just poisoned by floating debris, tend to jump the gun and the race from an organized starting point becomes a free for all. But in ventricular tachycardia at least most of the muscles are aiming in the right direction.
Ventricular fibrillation is like that, but everyone’s a winner, and they get the bag of dope before the race starts, so when it starts, no one can know which way they might go.
Electricity, though untested as a treatment program for drug addicts, works wonders on heart muscles. Like a cattle prod, it gets their attention and allows them to take a time of quiet, stunned reflection and then restart in unison as a happy and coordinated whole. Make no mistake though, they may be lashed together and working as a chain gang as they contract, but they are still individual cells that are mighty pissed off.
Posey’s heart arrhythmia was approached in two different ways. I immediately got the defibrillator charged to its maximum, and after spreading conductive gel on the usual spots on his chest, I shocked him with the paddles three times in rapid succession. After each shock, I checked the monitor – after the third shock, he converted to a normal rhythm -- although it was still crazy fast.
Another nurse gave him an IV injection of Lidocaine, while still another mixed up a solution of it and hung it from an IV stand and plugged it into a stopcock connected to the central line.
Lidocaine is a member of the ‘caine’ family – you may know other members of the family better – Cocaine and Novocain. All of them work the same, though some are more fun than others. It’s all about side effects.
Lidocaine numbs things up, and when given internally through an IV, it numbs up everything it comes into contact with. When it gets to the irritated parts of the heart, it numbs them up as well. The cells are still irritated and pissed off, but stop complaining because they can’t feel anymore.
There are side effects – sometimes it numbs the brain up as well and makes people stupid, and sometimes, when the levels get too high, it becomes toxic and starts killing the cells instead of numbing them.
And, it’s a cover up – it doesn’t fix anything, it just hides it, and when it wears off, the problems it was covering up roar back with a vengeance.
When the rhythm changed after the shock (defibrillation) the other nurses and doctors who had come in for the code began to drift off. The Balloon pump began hissing again more regularly and the franticness of the monitors alarms and flashing lights dimmed. I was left in the room with Dr. Lee, and a big mess.
I stood there and considered things. Posey lay in front of me on the bed, motionless and covered with goo. Blood was splattered in small splotches, and all the splotches could be traced to different causes. His heart rate was 120 beats a minute, and his blood pressure was 90/40. He had no spontaneous breathing – the ventilator was doing all the breathing for him. Hanging from his central line were medications – all maxed out at their maximum dose, and as I looked at them, I could think of nothing more to add that would help.
I stood there and looked at Posey and had a moment of clarity. I had no idea what to do next.
Without the clarity, I would have started something – cleaned him up, adjusted the lines or documented events in my notes. In the clearness of the moment, I found myself seeing the big picture – that it was over and that he was gone, and everything I did from this point on was just going to be a mechanical grinding – a going through the motions movement of wasted time, and compulsive busy work to keep me distracted and unfeeling.
I’d like to say that this made me do something I didn’t do. I’d like to tell you a tale of acceptance and loss – that I used the moment to reflect on the man who laid in front of me, of his life and the loss of it. I’d like to tell you I said goodbye and left him go.
I turned to Dr. Lee and said, “How about Dr. S. – is he available?”
I remember that Dr. Lee looked at me in the same way that I had just finished looking at Mr. Posey. You could see in his eyes that he was having his own moment of clarity, and that this clarity was about me. In that moment he was having a complete change in how he saw me – my motivations, fears, and seriousness. He saw that I not only cared, but, perhaps, that I cared too much. In his eyes, I saw that the thought seemed repellent to him.
Our relationship, Dr. Lee and myself, was based on distance. Neither one of us got too close to our patients, we both maintained a distance from them, and we both felt that our real skills came from maintaining this distance. Lee knew from his experience with me, that I could walk away from death without looking back, and that my caring ended when I walked out of a patient’s room to go home at night. He knew that I showed neither empathy nor sympathy for my patients, and that I treated them as a professional, and not a friend.
When I asked him about the availability of Dr. S., he knew what I was really asking – for him to call Dr. S and get him to come in and do something – something interventional – something surgical and drastic. I was drawing a line and asking him to step over it with me.
Dr. Lee looked at me for a long minute, then turned away and picked up his lab coat from the linen holder, and walked out of the room. He didn’t say anything to me as he left because he didn’t need to. I knew he would make the call.
Dr. S was a cardiac surgeon who worked with another cardiac surgeon, Dr. R, in a two-man practice that contracted with several hospitals in the area.
Dr. S was from Australia, and was obvious about it. He was what I called a slash and burn surgeon – the best kind as far as I was concerned. He saw things simply, as problems and solutions – you saw the problem then applied the solution. He saw no complications – he was too busy addressing problems.
And he also had a cute way of using the word ‘mate’ as a pejorative, and was married to a beautiful nurse who treated him like something found on the bottom of a shoe.
His partner, Dr. R, was from Texas, and gay. Dr R walked, talked and wore boots like a Texan. He also flirted with the female nurses shamelessly, like all surgeons are wont to do, but always stopped before sneaking away with them for torrid weekends of sex and other thing’s debauched. He was as big as all of Texas, except for the gay thing.
The fact that S was a cuckold, and R was gay, were not something any of us on the unit talked about, except in whispers and giggles when they were not around. Back then, neither of these parts of their personalities were considered fashionable or trendy, and if made common knowledge they would have severely impacted their ability to practice their skills or make money.
Both of them were good surgeons – fast, meticulous and detail oriented, all things you want in a cutter. In cardiac surgery, you wanted all three skills, but speed was the key. Both Dr. S an R got in and out quick, and their patients did much better because of this.
When I asked Dr. Lee about getting Dr. S to see Posey, I didn’t do it randomly – he was the guy I would have used if I need surgery. I wouldn’t want to sit around a room and discuss great literature with him, unless we were drinking, but, like a master mechanic, he had the goods when using his hands to speak for him. He was an artist in the operating room.
There were other cardiac surgeons that I worked with that didn’t have the goods. Dr. Cat was one – he had sausages for fingers, and a brain that ruminated on several levels of meaning before instructing his hands to move. He was slow and clumsy, and these things were not attractive in a cutter.
Dr. Cat was a great talker and teacher; he would spend hours sitting at the nurse’s station explaining the latest in medical thought. Most of his talking came in the form of lectures, complete with footnotes, pauses and summary statements, but it was all interesting stuff, if that was what you were interested in.
When I first heard the word pedantic, and then looked it up in a dictionary, I thought of Dr. Cat – but with affection, not derision – He wasn’t phony with his talk – it was clearly the way he processed thoughts and organized information.
I liked him, but hated taking care of his patients after he operated on them – they spent too much time on the by-pass machine, and leaked too much after coming back, because Dr. Cat tied poor sutures with his sausage fingers and took too long when doing it. A great person but a poor surgeon – he needed to focus on things that involved more talking and less cutting.
There were other cardiac surgeons available, but all had weaknesses, and none had popped into my head when thinking about Posey. Dr. B was female, and you just knew she had to be good to get where she was, but had an unfortunate combination of attention deficit disorder with obsessive-compulsive tendencies. She was also slow – molasses slow, and had yelled at me more than a few times, when yelling at me once would have been too much.
Dr. M was adequate – he seemed up to date with his knowledge, and used all of the latest and best techniques, but his patients all did poorly for some reason and I had my doubts about him because of this, and the way his eyes looked at something distant when he talked to me.
When you got Dr. S, you got Dr. R with him – they worked together like a well-oiled team. The only time that you got one without the other was when they took call at night – one would be available to answer questions, while the other did whatever they were rumored to do, in the privacy of their own, and expensive, home in the foot hills.
They were like the cartoon classic, Heckle and Jeckle, when together. You knew abstractly that they were different, but couldn’t tell which one was which when they were standing next to you. They had different personalities, and each took different roles in the conversations they were part of, but it was never clear who was who or what was what. They fed off each other in this way – completing the others jokes, cutting what the other held out to be cut – all without asking or apparent discussion.
I knew that Dr. S had several patients on the unit – one of them had coded a few hours earlier when I came in. I figured he’d be in to see Posey fairly soon, and spent some time trying to figure out what I’d say to him that would make the difference. Without surgery, there was no hope for Posey, but I kept telling myself that with surgery he might have a chance.


Sunday, May 16, 2010

Deadman, Chapter 22

Chapter 22

         By working through the things around Posey -- the trash, the lines and piles of tubing, I eventually got to Posey himself. He was the quietest part of the room, and easy to overlook with all the bells and whistles surrounding him, all screaming for attention.
         It took an hour to get him and the room cleaned up. I drew the morning lab work, arranged for the EKG after the chest x-ray was finished. I slung him up into the air to weigh him, and to get out of the way so I could change the bed linens. I padded the bed with extra linens, all piled on top of the first set and sort of lumpy --all with waterproof draw sheets. I was planning for a long day, with lots of leaking of fluids and other messy events.
 As I worked, I drank coffee continuously, grabbing refills from the central station. Even with all the coffee, I was close to tipping out of my chair before the sun came up and illuminated the binds in the room.
The charge nurse came in and told me that she was making Posey a 1:1 for the day shift. Good news and bad news – I could focus my time exclusively on Posey, but it also meant that I would have to focus on Posey because he was going to be busy.
When the hospital gave you only one patient, they were making a statement, because they were too cheap to do it without a good reason. I wondered what the night shift nurse was going to tell me when she finally got around to giving me report.
The charge nurse gave away the surprise a few minutes later when she came back into the room, pushing the balloon pump machine in front of her while asking, “What time did Dr. Lee tell you he’d be in.”
And then Dr. Lee walked in, right behind her.
A balloon pump device is deceptively easy to describe. It’s a long catheter surrounded by a thin balloon, connected to a pumping machine, and timed to trigger with your heartbeat. Think: An apprentice balloon artist that can only do snakes, and needs a straw to do even that. When he finishes the snake, he leaves the straw in – just in case the kid wants more air in it to make it longer after reflection. Add to that a half million-dollar machine to blow into the straw pure nitrogen – to inflate and deflate the balloon a hundred times a minute.
Most questions break down into parts, and the hard part is usually found in the why – it’s the overview place that most good questions revolve around, and something that needs to be explain fairly early in the process to keep others involved. When you use a balloon pump, the why is the easy part – To lower the SVR, and to pump additional blood into the coronary arteries. The how and the what, the mechanical parts of any question, are the puzzles to solve and the things left unanswered and iffy.
When the left side of the heart contracts, it opens the aortic valve and releases the pressure that’s built up in the left ventricle. Pressurized blood gushes out the valve as it opens, and heads up and around the aortic arch to then drop down towards the legs. Branching arteries along the way divert and direct the blood – to get oxygenated blood to the tissues and organs that need it.
The ascending and descending aorta are two parts of the largest and most important artery of the body. It’s big, wide, and straight for most of its length, and the ability of the muscles it’s wrapped with to expand and contract make up a large part the amount of blood pressure that’s used to perfuse the body with oxygen.
Right outside the aortic valve sit the coronary arteries. They look like small nostrils at the bottom of the arch, nostrils up and facing away from the valve. They supply all of the blood that the heart gets, and work by catching the backwash of blood that’s caused when the left ventricle contracts out the valve.
When the coronary arteries fail to, get enough of the backwash of blood, get pinched shut, or are blocked by clots or debris– the heart muscle that’s being fed by the artery dies from the point where the loss of flow starts and everything that lies beyond that point.
This is what a heart attack is – blockage, or bad blood flow that happens inside the coronary arteries.
The balloon pump was some crazy medical engineers solution to these problems – how to get more blood to the coronary arteries, and how to decrease the amount of resistance that the heart has to pump against.
Its genius is in its simplicity; its curse is in its practical utilization.
Art Lee took off his lab coat and draped it over the dirty linen holder. Turning to his left to wash his hands in the room sink, he turned to me and said, “Let’s start.”
I uncovered Posey and draped a sheet around his genitals to pull them away from the insertion site. I prepared the left groin area with antiseptic, and assisted Lee as he put on a sterile gown, after he opened a tray of equipment and spread its contents across the bed. I placed the separate heart monitor leads from the balloon pump machine to vacant areas of skin on Posey – The pump would use these leads to trigger the inflate and deflate cycles.
Lee poked the left femoral artery with a large bore needle and inserted the sheath into it, using the same techniques he’d used with the Swanz the day before, although this time the sheath was larger and he was inserting it into an artery and not a vein.
Lee used the left femoral artery in order to get a straight shot up the aorta. The balloon was large and wrapped around an equally large catheter, and didn’t bend well, so the less contorting it did until it got into position, the better. 
Once the sheath was in placed and secured with sutures, Dr. Lee unfurled the balloon. White, thick and bulky, it looked massive as it entered the sheath; it seemed impossible to fit anywhere in the body without blocking something important, but it was covered with a silicon lubricant, and in it went.
Lee threaded the balloon up the femoral artery, using some real pressure with his hands to move it against the current of the arterial flow that pushed against it. Once it was roughly at a mark he’d guessed it should be, a fluoroscopy machine was moved over the bed to give a better fine-tuning for its placement.
The balloon had to be placed precisely – the top needed to be at the point where the aorta started descending from its arch, and the bottom had to be above the renal arterial branching – so it didn’t occlude the blood flow to the kidneys and starve them of blood.
When the balloon was in position, Lee taped the whole shebang together to keep it from moving, and, using a hand held control crank, manually released the balloon from the catheter by twisting it counter-clockwise. At this point, he connected the hub of the catheter to the machine and turned the switch on.
The pump machine worked by cycling nitrogen into and out of the balloon rapidly – inflating it, then deflating it. Nitrogen was used in case the balloon broke, or leaked – because oxygen let loose in the arterial side of the body would stroke the patient out. The rate that the pump cycled at was set by the heart rate – at a specific spot in each contraction, the balloon would inflate, and at a specific spot, deflate.
An EKG is a representation of the electrical wave that’s generated by the heart. It’s a cycle of the hearts activities that is plotted on a screen to let you know what’s happening. Each plot and position of the cycle gets named with a letter, and each letter represents a different place in the cycle.
The letters used are, P, QRS and T. Each letter is a point along a wave that has a corresponding action in the hearts contraction.
P wave is the initial impulse that electrically signals the start of the contraction (depolarization,) the QRS is the contraction itself, and the T is the period of rest that the heart uses to recharge for the next beat (repolarization.)
The QRS wave corresponds to the time the aortic valve is open and the mitral valve is closed – and the left ventricle is pushing blood forcefully into the aorta. The T wave corresponds with the closing of the aortic valve and the opening of the mitral valve --and the left ventricle is at rest and passively filling up with blood from the lungs.
The balloon pump reads each cycle of the heartbeat and triggers when it sees the signals to inflate and deflate. When the sensor picks up the T wave, it inflates, and the bigger portion of the balloon then pushes all the blood in the aorta down and way from the heart, while the top part of the balloon forces the blood up and bounces it off the aortic valve.
Forcing the blood down empties out the aorta. With the next contraction of the heart there is less blood in the aorta because the balloon pushed it out. With less blood in the aorta, the new contraction has more room to put the blood it’s contracting, so the contraction faces less resistance, lowering the SVR and making its work easier.
And by forcing the rest of the blood up and bouncing it off the valve – the coronary arteries get more backwash forced down their nostrils. More blood in the coronaries means better perfusion of the heart – and more is better in this case – for something not getting enough, too much is a feast.
When the sensor on the balloon pump sees the P wave, it rapidly deflates. When the aortic valve opens at the QRS wave, it opens to an empty tube, and resistance is reduced to almost nothing.
So it’s a twofer – theoretically.
The problem, simply, is that the whole thing is a god-awful mess.
The insertion site where the catheter goes into the artery gushes blood with any movement – usually you have to put sandbags on it to keep it from leaking. The pump reads the EKG fairly well, but arrhythmias through it off, as do fast heart rates or any change in the rhythms at all.
But the big problem is that you have a large foreign object stuck in the major tube of the body that’s moving all the time. Things get push around, blood gets bruised and changes happen to both the clotting times and blood cells themselves – they get chewed up from the turbulence, leaving damaged free radicals and pieces of junk to float around the system and get caught in inappropriate places.
With the Balloon pump in place – oozing and rapidly hissing nitrogen, loud and alive with every heartbeat, I asked Dr. Lee what was happening with the surgical consult.
Lee said that Dr. Cat had been in at midnight to evaluate Posey, but that he had declined to do surgery because of the risk. I asked him, “why Cat,” and he smiled at me. “He was the next one up to ride in the barrel,” he said.
Lee depended on referrals much like Dr. Kanada, and when the results didn’t matter, he kept a rotating list in his head of who to go to next. Dr. Cat was a good teacher, but a lousy surgeon. I knew by his choice of Dr. Cat what Lee though Posey’s chances were.
As we were talking, the balloon pump stopped hissing and the room got quiet. I looked up at the monitor and saw that Posey’s heart rate was over two hundred -- he was in a wide complex ventricular tachycardia that indicated that the pump was without any pumping action. The arterial line reflected this by dropping to a pressure reading on the monitor of zero. There was electrical activity, but no coordinated heart contractions. He was dead until this got fixed.
I slapped the code button on the wall and started pumping on his chest with my hands to give him CPR.



Saturday, May 15, 2010

Deadman, Chapter 21

Chapter 21

I drove home in the dark and parked my car on the street, as was my habit. My wife and daughter met me at the door as I entered the house, and after a hug from both of them, I went to the refrigerator and picked up a beer from the lower shelf, opened it with a twist, and started drinking, as was my habit.
I was drinking Lucky Lager back then – 11 oz bottles that looked like they had been made in the war -- some old war that nobody cared about or remembered. Under the cap of each bottle was a cryptic, sign language quote or saying  -- done in pictorial stick drawings, with plus signs to indicate connections – they might have been meant as short essays for drunks, or served as warning notices for other peoples, those limited in attention and those not driven mad by unclear portents.
I had stopped reading the caps by then, too much trouble and no longer fun to figure out. I drank for effect --the cheapness of the bottle, and what they contained, was more important than any brief instructions that could be obtained from the signage on the outside.
I wasn’t a social drinker, but I wasn’t a drunk either. I drank for effect – for sleep, or to shut down my thinking -- which I considered the same thing. I never went out to have a drink with buddies, if it were just for fun, I’d rather have a coke.
But I wasn’t in control either.
After watching a sit-com with my daughter – me in a big recliner and her sitting on my lap snuggling, I put her to bed, went to the bathroom and pulled out a half full syringe of Valium, unscrewed the plunger and drank the contents from the barrel. I returned to the watch TV, finished another beer and then went to bedroom to get some sleep.
A line was probably crossed, but it wasn’t clear to me at the time, or for a long time after. Taking home leftover drugs and using them was not normal behavior, though it seemed so at the time – what was I supposed to do, waste them?
I may have seen the line I crossed in a sense – it was pretty obvious, but as any drunk driver going the wrong way on a freeway knows:
Bot’s dots, when seen going backwards against the flow of traffic at night, line the road with red, not white, as they reflect off headlights – The traffic bumps no longer serve as guides on a path, but have become warnings of impending doom and stupidity.
You might notice the rhythmic flashing of red as your car speeds steadily down the freeway against the traffic, and even comment on the strangeness of it, if only to yourself. You can see what’s happening, and even count the bumps as they pass you, but you aren’t capable of understanding the meaning of their redness, or of how you got there, or why you should get out quickly -- the consequences in other words, until smashed and damaged, you cry like a baby at the getting caught of it all.
   I could see the line, but had no vision of what it meant. I was in the now, but not the now of the Buddha, but the now of obliteration into obliviousness.
I started using drugs when they first became available to me – it was never a question of whether or not I would, it was always a question of when. I smoked when I could get cigarettes, I drank when offered beer, and used drugs when they were available to me. I never thought of it as a question of choice, only as a question of dosage. I used whatever I could to change the way I felt – sometimes easily, in the simplicity of books, and other times with the harshness of pain. Tools, dosage and escape -- the trinity.
It was simple and unquestioned – I didn’t like the way I felt, so I looked for ways to change it. Like I said, life was about dosage – getting the numbers right.
I grew up in the right age for this kind of thinking, and found it easy to surround myself with others with the same goals. But, although no big punishment of awakening happened to me – no arrests, or the loss of jobs -- living as a casual abuser of drugs was limiting, and as I aged and took on more responsibilities, I was not prepared for them, I’d never done the practice work of being uncomfortable.
I became more workmanlike in my drug use as I got older, usually with alcohol and sedatives – things that made me feel normal, and things that slowed my thinking down enough to allow me to get some sleep.
To be honest, I didn’t think about it – drugs were just a part of the spiritual toolkit I used, one that I had to keep secret for legal reasons, not moral ones.
I reasoned, if I bothered to think about it at all, that if I told someone what was going on in my head, they would have seen the need, and given me the drugs – I was just removing any of the moral dilemmas that could come from the asking by taking care of it myself. It also occurred to me that if I said anything to anyone, they might want to fix me the hard way– and that was not a thing I imagined as a survivable event.
I look back on the person I was with regrets, but also with understanding. What I did for the reasons I did them are unimaginable to me now, but they were real, and I still bare the scars of them.
I slept like the dead.

Day 3

Evidentially, the phone rang. My wife nudged me awake by kicking me a few times, and then handed me the phone, “It’s the hospital,” she said.
I answered by talking into the handset, asking what the time was. My wife said, “too early,” but the voice on the other end of the phone said three.
“Can you come in, now?” asked the charge nurse.
“Yes, as soon as I can wake-up,” I answered. I didn’t ask her why she was asking, and she didn’t tell me.
My wife was up, so she made me coffee while I showered. By the time I got toweled off and dressed, she was back in bed and asleep. I loaded up the travel mug with coffee and drove to work.
After parking in a doctors slot near the entrance, I went though the double sliding doors of the ER, and after showing my badge to the off duty cop, cut through a maze of gurneys and headed to the forth floor.
It was a zoo in the unit, and feeding time as well. I found the charge nurse going from room to room with a large garbage bag, picking up the big pieces of trash from each room, and then moving on to the next.
Three patients had crashed shortly after midnight, and two of them were still in the processes of resuscitation (coding,) She told me to pick up Posey for now, and to get report from the nurse I was relieving when things settled down. I saw Posey’s night nurse in one of the room where a code was taking place and yelled at her that I was taking over his care.
Posey was just as I left him, only trashed. The bed was covered with spots of blood; the tubing from the ventilator was loose and not connected to anything – and was alarming shrilly. One IV controller was beeping that it was empty, and it wasn’t, and another wasn’t beeping and it was empty – air was backed up in the line almost to the hub. The Swanz-Ganz reading was mushy and needed attention – the numbers were crazy, but not crazy enough to be true. Everywhere was mess and everything was stained and all was sticky to the touch.
I started by picking up trash in an attempt to uncover things.
I did not leave my patients clean and their equipment organized because of some built in and innate sense of order. I did not do it because it was easier, or because it made other people happy. I did it because the pain that happened if I didn’t do it hurt a lot.
I’m not rewarded by the pretty; I’m punished by the ugly – that’s the simple lesson for understanding my motivations.
Most of life is about getting presented with something and then doing something about it. When it’s over (the Lesson,) you then do a critical review of what went right, and what you would do the next time to make it better (the Learning.) Life is about doing this over and over, until you die, sometimes with small things and sometimes with the larger.
Neatness is generally about control, but with patients it’s more about the outside control than the inside. The first part of control is figuring out what you want, but the key, and more important part, is figuring out how to get it. In nursing, you want to get things into and then get things out of– and control is in the access. Access is in knowing where everything is and where everything is going. With this knowledge, and a few buckets to catch what's left over, you have control.
An Anesthesiologist taught me about neatness by not having any. Dr. P was and old-time doctor in the worst sense of the word. Looking like a melted Ronald Reagan, with thick hair dyed brown, he grandfather claused his way through medicine without any aptitude or skills, and relied on the kindness of others to not kill his patients. Most of the time, the others in his group assigned him to simple cases, but when he was on call, he covered everything.
I received a patient from him after an open-heart case and learned some hard lessons about both neatness and faith.
After open-heart surgery a patient comes back to the unit for post-op care ice cold, obtunded and with every line possible or desired poking out of every hole in them, man-made or otherwise. From the IV’s hang drugs – none on controllers, because that would be too hard to transport, and many of them duplicates of each other in all but name --and many potent in their actions. The patients come with breathing machines, bulking dressings, chest tubes connected to boxes that are supposed to suck on them, pacer wires, intended to be connected to the heart, but only taped to the chest when you get them, and a tube through a nose that’s supposed to be in their stomachs.
All of these things need to be checked and connected to gas, suction, pacers and controllers. And all of this needed to be done quickly, while the half dead and frozen patient is being manhandled without monitoring into the bed you had assigned him.
Most of the Anesthesiologists take a level of pride in how they hand over critical patients to you – most label the lines -- and some will hand them to you individually, while telling you tales of how things went, the complications, and what to expect. The transfer from the OR to the unit is dangerous and stressful at best, but with a good doctor, and some basic help – it’s manageable. It’s why we get so much training, and why we make the big bucks.
Dr. P brought back his patient from the OR with all of the lines crammed into two separate paper grocery bags – one for the left and one for the right. They were secured by large red rubber bands and tape. Alone with me in the room, he left immediately after helping me slide the patient over to the bed, saying, evidentially to me,  “Here you go girls,” as he walked away. I was the only one left in the room as he walked away.
I was left standing alone in a room with a critical patient and had no idea of where to start. I was paralyzed with inaction, the task before me seemed overwhelming and impossible. As I stood there, I really thought the patient was a dead man, and my mind whirled with thoughts of excuses and things to blame. But what I did was different than my thoughts.
I connected his breathing tube and started the ventilator. I unwrapped the bag and found the arterial line, and connected it to the monitor. I put chest leads back on him and connected them. I found one IV that looked good and set it up on the controller. I found the drips of medicine and connected one of each type into the main line IV I’d chosen.
I did stuff, trusting that my training would lead me to the next right thing, but also trusting that it would all work out until I got there. At some point in the doing of things, I looked around and up, and saw that the room looked more organized, that I had a handle on what was going where, and also what should go where next. Eventually I had things arranged exactly the way I wanted them, and was in control again, for the first time.
Neatness and faith – two lessons I learned that night from an idiot.