As I returned to the nursing station from Mr. Posey’s room, I saw his wife outside the double doors that led into the unit. She had cornered Dr. Q. and was apparently getting some questions answered. He looked uncomfortable, as if he’d been forced into a corner by a mad bear. Animated, she was gesturing with her hands accusingly, thrusting her fingers at him to emphasis each of her accusations. She was obviously attacking Dr. Q for some unnamable form of sloth or malfeasance. She was not pausing to listen to his answers, when he tried to talk, she’d take a step closer to him and continue to make her points with her hands. Things were heated in the hallway.
All this was done in a loud voice that was easily heard from inside the unit. She was telling him to do something – to get her husband back to her. When she finished with Dr. Q., she turned from him abruptly, slammed the wall door opener with an open palm and walked past me without a look as she marched into her husband’s room.
Dr. Q. came back into the unit from the hallway, and without speaking, picked up Posey’s chart and walked away to another part of the unit. A few minutes later, he called the unit and told me he had written new orders, and asked me to pick up the chart from him in the break room. I walked down the hall and grabbed the chart of a table in the nurse’s lounge. Dr. Q. was not there; he’d escaped out a back door and was long gone. The amazing thing was, the unit didn’t really have a back door
The unit consisted of 14 rooms in a semi-circle, with a big central “L” shaped counter area in the center area. The entrance was a set of double doors that opened with a wall switch. Upon entering, there were two rooms to the left of the doors, and then a sweeping curve of rooms that went from left to right. To the immediate right upon entering was a narrow hall – to the left of the hall was the center “L” shaped counter which functioned as the nursing station, to the right, all of the storage, conference and preparation areas. Behind these areas and on the final wall of the unit, were a couple of locked doors – locked, and blocked by large portable machines that were used for various tests that unit patients needed occasionally immediately.
The entrance placed the bottom of the “L” shaped counter, and this was where the patient monitors were stacked. The long and main section of the “L” was a combined desk and counter. The desk area was wide, with phones and writing equipment placed every few feet. The charts were normally placed along the center of the “L,” but were usually were found scattered around the desk in various stages of being paid attention to.
On day shift, a ward secretary sat at the nurse’s station and transcribed doctor’s orders as she watched the heart monitors for arrhythmias. Rolling chairs to be pushed or pulled, were scattered around the station.
The counter area ran the entire length of the “L.” It was wide enough to hold a chart stable while updating notes on patients.
Against the walls, and directly outside of the patient rooms, were rolling medicine carts, heavier code carts, EKG machines and respiratory equipment, as well as anything loose that might be needed quickly.
Each of the 14 rooms was built to hold one patient, and all the equipment needed to care for them. In each room there was a big wall length stand behind the head of the bed that housed all of the conduits -- the central suction and gas supplies and other required tubing’s of medicine. The stand also held a giant red panic button, a wall clock with a digital timer and the TV controls.
Next to the bed and to the side of the wall, was a replaceable cart with supplies for each patient – the cart was changed with each new patient and held dressings, ointments, linen and IC supplies and tubing. A reclining chair came with each room, for either the patient or the family to sit on (only 2 immediate family visitors were allowed in the room at one time, and only one could sit.) A small window at the back of the room was covered with a plastic blind that was kept closed most of the time. The window opened only at the bottom, and only a few inches. A small “hopper” at the back of the room was used to dispose of fluids. In each room was a garbage can lined with a red bag for soiled stuff, as well as a blue bag that melted when thrown in a washing machine, for soiled clothing.
The monitor was located at the head of the bed, on the central pillar. Cutting edge, which meant it had a colored screen for viewing, each of the monitors had a large CRT screen with a row of removable modules lined beneath them. Each module had a specific function, and all of the modules were interchangeable. From the modules, hard lines snaked out, to be attached to whatever monitoring device they were intended for.
Not much space in the unit went unused. Pieces and parts of various machines were stored in all the available corners and angles, all on spots marked with tape on the floor. The floor itself was tiled in a random black and white, and without any apparent order; it was seemingly picked and placed from random piles. The floor was kept clean, but was scared with lots of old grooves worn by machines and beds. The walls were painted a bland off yellow color, and a few scattered old prints hung from the walls. All of this was harshly lit under a recessed florescent lighting system.
In many ways the unit was a firetrap waiting to happen. I decided that Dr. Q. would be a good person to stay next to if I ever needed to run away quickly -- he seems to have mastered the basics of escape.
Dr. Q. left only a few orders:
Dopamine gtt., titrate to keep SBP > 110
Consults: Art Lee for Swan insertion, Kanada to evaluate for ET placement, (I will contact.) Kanada to follow resp.
After Swan placement, call for orders after initial numbers obtained
NPO, change p.o. meds to IV – D/C Inderal
Mrs. Posey had squeaked enough to get some action, but I wasn’t sure if she and Mr. Posey understood what the action was going to look like when it happened. Before I mixed up the dopamine and started it, I went into Posey’s room to talk about the future.
Mrs. Posey was standing at the bedside and talking to her husband softly. I asked them if the doctor had asked him about what he wanted done. He said no, that he left the doctor stuff up to the doctor. She said nothing, but watched me intently, waiting for me to talk first – not waiting to see what I had to say, but waiting to see how I said it.
I told him that I felt he was getting worse, and worse rapidly, and that at some point soon, a doctor would probably have to put a breathing tube down his throat to keep him breathing.
He told me simply, and with few words, that he didn’t want to die right now, and that he wanted me to do whatever needed to be done. He said that he didn’t want to give up living.
When he finished telling me what he wanted, something inside of me changed. He wanted to live, but I knew that he wasn’t going to, that everything we did to him, every intervention, every poke of a needle, would all make no difference – he was going to die. I knew this, and suddenly it made no difference. I decided he was going to live and that became my mission.
I’ve never been a joiner, or been a part of any crusades. I flinch at the mention of religion, as if it were the flame of a hot stove. I have always tired to see things the way they are in spite of what I want them to be. I’ve always been brutally honest about myself, and have tried to carry this message to others. I’ve never tilted at other people’s windmills, and never pretended something wasn’t true just to make me happy.
So, this was different, and it happened to me in an instant. I was now working for the man, whose name I did not know, and whose wonders I’d never believed in.
I think that Mrs. Posey saw the change. She reached over the bed, took my hand and squeezed it, and then she let go and walked to the back of the room and sat down. I left the room to get started.
I returned to the room and started the Dopamine. I rapidly turned it up to get the effects of it to kick in faster. His heart rate was already too fast, and the dopamine made it go even faster, but there was no free lunch in life, and, besides, I was committed. Posey’s blood pressure came up quickly as I continued to watch him for any troubles that might happen with the drug was first started. After a few minutes of nothing much, I walked back out to the nurse’s station to make sure that the consults Dr. Q. had requested were going to happen on my new time scale.
Dopamine was acting to increase his blood pressure, and to make his heart contract with more force. In many ways it was acting like the natural adrenalin the body produces to speed up things, but it was slightly easier on the body – it kept the forcefulness of adrenalin, but didn’t clamp down the arteries as much. It beefed up the forcefulness of contractions, without making the tubes this forcefulness contracted into smaller and more resistant to the force.
The problem with dopamine is the same as the problems caused by snorting crank. You get a short-term boost of energy – you can iron every bit of clothing you own, you can vacuum your cat and lift a car off a small child, but you have to pay for it at some later point. Like crank, when you are on a dopamine infusion, eventually you are going to end up in as sweaty pile of depressed thoughts and flaccid muscles, with a groomed kitten licking salt off you as you cry. But sometimes it’s worth it.
The thinking behind the use of dopamine is: that it gives you time, time that your damaged heart can use to stabilize itself. If you survive the first five days after a heart attack, the damaged and bruised areas of your heart can scar over and, even if they continue to be a problem area, the heart can get back into functional action without blowing a wall out. It’s an inside version of an outside road rash – If you wait a few days, it’ll scab over and at least stop leaking everywhere. A scab is not skin, but it’s functional enough to keep the germs out. It’s like that.
The problem with dopamine is: Solving the problem of heart damage by working the heart harder doesn’t make sense. It may give time, but by increasing the pressure inside the heart, you are increasing the possibility of blowing out the heart. Think of the weak and damaged areas of the heart as the weak and damaged section of a water pipe – if you try to fix it by flushing it out with a blast of increased water pressure it might work, but it probably would just blow the damaged section to pieces and take the whole system out of service.
Dopamine was the aggressive move for Mr. Posey, and it was the aggressive poor chances move of a desperate gambler. But the safe move of not using it was the sure thing folding of the cards that a loser, anxious to get out of town would choose– a quiet death at home with those you love.
My job used to be to help people get home, but now I was urging them on to battle against a house that never loses.
I talked to Dr. Lee’s office, and got a late afternoon expected time of arrival time. Dr. Kanada was in the building making rounds on his other patients and was expected to get to the ICU soon. I called the respiratory care department and asked a technician to bring a ventilator up to the unit as soon as possible.