Flat on his back, under bright lights, Posey lay with his chest exposed, waiting.
I rubbed his upper chest with an antiseptic solution to clean the area off, as Dr. Lee opened a sterile kit containing all of the basics used for putting in a central line. Another kit sat near him, this one containing the Swanz-Ganz catheter that he would use after he placed the initial catheter, the CVP line.
Finding a landmark, below the scapula and on the upper right of Posey’s chest, Dr. Lee stuck him with a large hollow needle that was attached to a syringe. He pushed it about a quarter inch deep before straightening it out and hitting a vein. After seeing a flash of blood coming from the hub, and into the syringe, he pulled back on the syringe’s plunger and watched it fill with dark red blood. Comfortable he was in a vein and not an artery, Dr. Lee removed the syringe and, as blood dripped out of the hub, ran a thin guide wire through the needle and into the vein.
With the guide wire in place, Dr. Lee carefully removed the needle, taking caution to not disturb the wire accidentally as he removed the needle. Picking up a scalpel from the tray next to him, he made a small incision at the puncture site, to allow additional room for the large catheter that he needed to put in next.
From the same tray, he took a large, pale blue sheath and inserted it by running it over the wire and into the vein. The sheath, called an introducer, was placed to act as the container for catheter to follow. He checked the placement, again, by drawing blood from the hub of the sheath with a syringe. Satisfied that it was still in the right place, he sutured the introducer to Posey’s chest.
Dr. Lee then opened the Swanz-Ganz catheter kit and inspected it for flaws. He then used a syringe with air in it to check that the balloon at the tip of it would inflate properly. I held the tip of the tubing that was connected to a bag of IV solution out to Dr. Lee, and he grabbed it and connected it to the catheter, and then flushed it with the solution.
Inserting the Swanz-Ganz through the introducer, he both pushed it slightly, and allowed the natural pressure of the flow to carry it to the right side of the heart. When the bedside monitor alarmed and indicated that the catheter had entered, and gone through, the tricuspid valve in the right side of the heart, Lee inflated the balloon at the tip of the catheter, and allowed it to float on until it became lodged in the pulmonary artery.
This was the wedge pressure – the place where the indirect measurement of the left side of the heart good be taken. Dr. Lee asked me to write down the pressure reading showing on the monitor, and then pulled the catheter back an inch and taped it – to keep it in place, and to prevent it from moving forward accidentally and damaging the lungs by occluding the flow distally from them for to too long. It was fine to occlude it for a measurement, but left blocking the flow for too long and everything beyond the occlusion would starve from lack of oxygen and die.
Dr. Lee finished and left the room, asking me for the numbers as soon as I could get them.
After he left, I cleaned up the mess that the packaging and the sprays of blood had left, and then put a dressing on the insertion site of the line. I change the IV’s going into Posey’s arm into heparin locks (I capped them with a plug,) and rehung the solutions that had been hanging from them, attaching them to the port on the Swanz-Ganz catheter with stopcocks. I made things neat and labeled the lines enough to make me feel comfortable with where they were located if an emergency came up.
I then did the numbers for Dr. Lee:
Using stopcocks connected to the Swanz-Ganz line, I first took the pressure reading from the right atrium (RA,) the area where blood first enters the right side of the heart. Normally, the numbers ranged from 0-10, Posey’s was 23. This indicated that there was a major backup of blood waiting to be pumped – he had a high preload number.
By turning another stopcock, I got the pulmonary systolic and diastolic pressures. Normally less than 30/10, Posey’s was 45/22. This indicated that there was a lot of fluid just hanging around in the heart, and that it wasn’t being pumped out very well, or with any urgency.
Of the two, the pulmonary diastolic pressure (PAD) was the important reading – when all of the stopcocks were placed in their normal positions, the PAD was the reading you saw continuously scrolling across the patient monitor. The PAD was also a good indicator of the wedge pressure, though not as accurate. The PAD was usually 3-5mm less than the wedge, and useful for ballpark guessing of what the wedge was without occluding anything.
The next measurement did not require me to turn a stopcock, just to inflate the balloon part of the catheter with a small amount of air -- to get it to wedge in the distal part of the pulmonary artery. A normal wedge pressure is between 2-15 -- Posey’s was 29. Since this pressure reflected the pressures from the left side of the heart, it showed that the pump was in failure – backing fluid into the lungs, and that it was struggling to get blood out of it.
In order to get the next numbers, I set up for a cardiac output (CO). Using iced syringes, each filled with 10cc of saline, I injected them, one at a time, into the RA port of the Swanz-Ganz, while pressing, and holding, a button on the special cardiac output module that was connected to the monitor. By measuring the differences in heat loss, as measured by the special thermometers built into catheter, each injection of iced saline was converted by a simple computer and gave a number that indicated, in liters per minute, the output of the left side of the heart.
When I finished pushing the iced saline, numbers were automatically generated by the computer and then popped up on the monitor. The cardiac out put was low at 1.4 and the SVR was high at 1800. None of this surprised me, but it was worse than I thought. A normal CO was greater than 2.5 and a normal SVR less than 1200.
The heart was pumping poorly, and was pumping against a lot of resistance.
I wrote down the numbers, took them out to the desk and left them with Dr. Lee. I then returned to Posey’s room to get him cleaned up, and the room organized.
I turned Posey myself because I rarely asked for help. I tucked the linens under him as I pulled him towards me, and held him on his side as I put the new linens in place. I included a few waterproof pads and new draw sheets -- this was a different kind of linen change.
One sheet was for pulling him up in bed if he slipped down, and the other for his upper chest area and head, to protect the bed from the new lines now running into his chest, the leaking from the ventilator tubing curling away from his mouth, and blood spots from when I drew lab work from his arterial line.
Rolling him back over the hump of the linens, I held him in place and reached over and tucked the edges in. All of this was to make things neater, and to make it easier to clean him up at the end of my shift. This measured us, us nurses – how neat and clean we left our patients.
Back on his back, I separated the lines individually and pinned them to the upper draw sheet with a safety pins. Each line was placed in a neat row and labeled with the drug or solution going into them. The labels were all face up and aligned with the tubing horizontally. Everything was now in its place.
What I was doing was cold, unfeeling, and mechanical. That doesn’t make it untrue. Distractions come in different forms – some people shop, others obsess over gains and losses – I worked the details.
I took pleasure in working the details -- making corners tight, and the chaos of the small ordered. I did what was in front of me to do, and took comfort in it – I worked with the mastery of experience and practice, and understood each movement of my hands and body without having to think it through in my head before I acted.
If you asked me, I could break down the numbers and give you the well-reasoned treatments for each. I could then manipulate the machines and fluids to then hit the numbers spot on, without any ups or downs on the way.
What I couldn’t do was fix the heart. No matter what work arounds, by passes or augmentations, I couldn’t give Posey a new pump, and all that I was doing was supporting him in a failing crusade – putting my finger into a dike made of rotting cheese, while giant storm waves pounded it in the rain. The dead and dying tissues that made up his heart were flexing and contracting with every beat of his heart, and like bruised fruit, something soft and mushy was going to give, and give soon. So, I focused on the comfort of detail.
Posey was minimally responsive -- he withdrew to pain and his pupils reacted to light. Whether it was the sedation, or because his brain wasn’t getting enough oxygen, I couldn’t tell. At the time it made no difference – he didn’t have to be awake or contributing anything to be part of the process.
Dr. Lee brought the chart back into the room and went over with me the new orders:
Dopamine gtt. Keep BP> 90/sys
Nipride gtt. Titrate for SVR to keep <1500
Maintain Ntg gtt. As tolerated
Change lasix to 100mg IV q2hrs.
Keep pacer pads on, temp pacer at beside – off for now
Surgical consult (I will contact)
Hb., Hct., Chem 7, now and g4hrs. Port. CXR for placement, Ekg,CBC,Chem20,PT,PTT,CXR qam. Pt,PTT now. Call results
Replace K+ to 5.0, use unit protocol
I started with the Nipride.
Mixing it in the dark of an equipment room (light deactivated it,) I added the concentrated solution to a small glass bottle, then wrapped the bottle with aluminum foil and taped it up to keep all light out. I then took it into Posey’s room and hung it up, plugging the tubing into the stopcock closest to the heart.
Nipride was tricky – we used concentrations of it so non-diluted that increases in the dosage were done in single digits, short turns of the knob of a controller. The push of gravity from the bolus doses of other medicines could flush it into the heart and bottom out the pressure in an instant. It was important to keep it away from other solutions, it didn’t play well with, well, anything.
Nipride was a smooth muscle relaxant that didn’t discriminate, it dilated all smooth muscle, but seemed fond of the muscles that wrapped the arterial walls, and dilated them with gusto.
When you think of veins and arteries, muscles don’t usually jump up as the first image. But muscles are the biggest part of veins and arteries – they are made of layers of muscles that surround a thin slick lining of slipperiness.
They use their muscles to control the blood pressure and to make sure the right amounts of blood get to the right places. Like a traffic management system run by German’s, the veins and arteries widen and narrow according to demands and needs, as sensed by special cells of nerves planted strategically along them.
Like all thing of the heart, the muscles on the right side – the veins – were much weaker than the left. Working with lower pressures, their usual response to almost anything was to roll over and show their bellies – they got flaccid and loosened up. They had a minor ability to tighten up and thereby increase the blood pressure, but tended to rely on gravity and inertia more than flex.
The left side system – the arteries – were beefier, and much more aggressive. When they clamped down – they clamped down. When they relaxed, they snapped to it – they didn’t surrender or let go; they sprung to another position aggressively – they never retreated from a battle, they just started attacking from a different direction.
With the Nipride started, I dragged the temporary pacemaker from its taped spot in the hallway and plugged it in to a wall socket near Posey’s bed. I removed the sticky pads from their wrapper and put one of them on his chest, and then slightly turned him, to place the other on his back. I left the pacer turned to off but ready to go.
The temporary pacer would be turned on if Posey’s heart rate went crazy – either too high, or low. It worked by delivering a jolt of electricity to the heart at a rate that could be set by turning a knob. It acted by overwhelming the regular electrical activity of the heart – overriding it to reset the rate.
Using the arterial line, I drew blood for the lab work that Dr. Lee had ordered and arranged a runner to drop it off. When the technician arrived to do the chest x-ray, I had him assist me with replacing the sheets under Posey -- we had to put a plate under his back any way, and I occasionally remembered to ask for help.
When the night nurse came, I was ready to go. I gave her a quick report and headed home for the night. I was due to be back in 12 hours for another day.