Saturday, July 2, 2011

Fourth Chapter

Nancy
In which we learn the circumstances of a most unusual bequest
  All patients coming to the OR are given a score on the ASA Physical Status Scale. The score from this scale correlates very closely with the probability of complications for an individual. The higher the score, the more likely complications will occur, and the more likely the complications will be serious. The Scale goes like this:
ASA 1 – A normal healthy patient with no co-morbidities
ASA 2 – A patient with mild systemic disease, such as diabetes controlled with diet or oral drugs, or an obese patient, or an otherwise healthy patient who smokes, or a patient with well controlled hypertension.
ASA 3 – A patient with severe systemic disease and or co-morbidities, such as poorly controlled diabetes or diabetes with renal impairment, or morbid obesity, or heart disease or angina.
ASA 4 – A patient with severe systemic disease that is a constant threat to life, or combinations of severe systemic diseases such that there is an imminent threat to life.
ASA 5 – A moribund patient who is not expected to survive without the operation.
  ASA 6 - A patient declared brain dead whose organs and or tissues are being removed for donor purposes.

  It began with a call from the warden at the State Penitentiary. A death row prisoner, scheduled for execution in a month, wished to donate a kidney to his mother who had end stage renal failure. The Governor had approved the prisoner’s request. The Chief of Security from the Penitentiary came to look over the Hospital and OR, and to plan the donation with the Hospital staff. They met in Chicky’s office. Included in the meeting were Nancy, the head nurse of the transplant team, and Dr. Mike Moatz, the transplant surgeon. Chicky’s office was in a former supply storage area, just large enough for her desk, four tall filing cabinets and a small table with four chairs. No windows. Each of the filing cabinets was of a different color, the chairs were mismatched, and the desk looked like a survivor of the sixties. The chair behind the desk was new looking and of the quality the office supply catalogs called “Executive”. Four Diplomas hung on the wall, one from a hospital school of nursing, a BS in Nursing from a state university, A Masters in Nursing from a small Catholic University, and an MBA from another state university. On the desk was a new top-of the-line Intel Quad-Core laptop purchased by Chicky personally, with Molly’s advice, to replace a generic and antiquated Pentium III PC provided by the hospital. Chicky had always been amused to note that the computers in the executive suite were always the newest and fastest models while those used by the actual workers throughout the hospital were always a generation or more behind.  Chicky’s Spartan quarters were on a par with other nurse directors/managers and did not compare with other non-nursing department heads well. Those Physicians among the hospitals officers had the most palatial offices of all. It was no coincidence that the staff referred to the area of the executive offices as “Mahogany Row”. Office décor in the hospital was a matter of stroking egos.

  It took little time for the Chief of Security to outline the requirements for the situation. The prisoner had a violent history, and had been involved in several altercations with the guards. A condemned man, he had little or no incentive to be cooperative. He literally had nothing to lose. Solitary confinement, being fed on “The Loaf”, had no observable impact on his demeanor. “The Loaf” was the modern equivalent of bread and water, being a bread-like mass concocted of various food items making up a complete nutritional diet in a monotonous and unappealing cube.

   After much discussion, a plan was formulated that accommodated the sterility and operational needs of the surgical procedure and the restrictions necessary for tight security. Everybody’s thoughts were of a hostage situation or worse. It was obvious that the Chief of Security thought the whole matter a bad exercise of judgment, but you don’t argue with the Governor. The OR staff was focused on the need for the kidney in the knowledge of the scarcity of organs. The average time on the waiting list for a kidney was seven years. Ten years was about as long as a person could go on dialysis, so most transplants were the best match available, often quite short of a perfect match. This meant that the recipient had to be put on large doses of immune-suppressants and steroids to avoid organ rejection. This in turn made them very susceptible to infection and other disease processes, yielding a shorter life span than a really good match.
  Nancy changed out of scrubs in the locker room, and walked to the parking garage. She got on the lift which rose past the levels reserved for physicians, the levels for administrators and arrived at the open season levels next to the roof. She located her well used minivan which bore all the signs of children: toys, food stains, a child seat and cartoon stickers on many of the interior surfaces. On the drive to one of the suburbs of tract homes she had the radio tuned to NPR, but wasn’t hearing it, being lost in thought about the upcoming “harvest”, as an organ donation was known to the surgical community. Nancy had flown to remote hospitals, and been in most of the hospitals in the metropolitan area for organ harvests and had even been to the Medical Examiner’s office down town to recover cadaver skin, bone and corneas. But this harvest was hands down the weirdest of all.

  That night, after the children were bedded down, and before Nancy’s husband Steve headed out for his night shift with the police department, Nancy asked if he knew anything about the unusual organ donor. “He’s a real bad one” Steve answered, “He shot and killed two men in a drug deal that went bad, went home and to top it off, beat his girlfriend to death with a chair. In my view, death by lethal injection is too good for him. You guys should take his kidney and then not bother to wake him up.” He hugged and kissed her, went out to his police cruiser and headed off to the station. In the days leading up to the harvest there was much discussion among the OR staff, and Steve’s opinion seemed to be shared by many. Most organ donations were from cadavers, brain dead from one cause or another. A nearby state did not have a helmet law for motor cycles, providing a steady stream of donors such that Nancy’s team mates began to refer to the machines as “donorcycles”. The first time Nancy had seen the respirator and monitors turned off with the brain dead donor still on the OR table, all the monitor tracings going flat, it creeped her out. Nancy had participated in live donations before, with the donor a close relative of the recipient, and the two surgical procedures being carried out simultaneously in adjacent ORs. This time, the recipient would be in another hospital about an hour’s journey away from the donor.

   The night before the harvest, Nancy tossed and turned. There were so many implications of the harvest that were troubling, not the least of which was a report in the news of organs from executed prisoners being marketed in China. News of the harvest had also leaked to the media the day before. The botoxed anchor of the local TV news and his generic surgically enhanced blonde sidekick, half his age, reported with earnest, serious expressions that the prisoner had refused all appeals, and wished to die rather than spend life behind bars. The leak also created a fear of a media circus descending on the hospital. Nancy had a mental image of a large crowd with signs and banners on the front lawn being led in protest songs by a banjo playing Pete Seeger. Opposite was Rush Limbaugh leading a crowd with “Roast in hell” and “Bring back public hangings” signs. Due to security concerns, changes had been made in the plans for transport of the prisoner, security around the hospital increased and a public relations campaign planned.

   On the morning of the harvest, Nancy arrived at work as usual. There were no TV vans with satellite dishes, and no Pete Seeger, which calmed one of the anxieties fluttering in Nancy’s stomach. She changed into scrubs, checked the schedule board, noted that the harvest was on first as she had expected.
Donning her surgical mask, Nancy went to the OR and began arranging the equipment, checking that all was in proper working order. Then she went through the small substerile room that was shared by the two adjacent ORs. The substerile room was an area containing a sink, an autoclave for sterilizing items, and a warming cabinet for keeping blankets and fluids slightly above body temperature. Some linen and other supplies were stored there as well. Nancy made sure that the area was clear to allow free passage through the substerile room. Security dictated that no instruments or any objects that could be used as weapons could be in the OR with the prisoner until he was under anesthesia and unconscious. So Nancy and her scrub tech Tim would have to open up their sets and supplies to set up their sterile table in the adjacent OR and then move it through the substerile room when they got the signal. Tim was already in the next OR, and had gathered all the needed sterile sets and packs. He left the OR to scrub up, and Nancy opened all the sterile items. When Tim returned with his hands raised in front of him in the manner familiar to all who have seen Medical shows on TV. Unlike The TV shows, masks are always worn while scrubbing, and by anyone around someone scrubbing, and always in the OR. It was a favorite pastime of the nurses and techs to spot all the breaks in sterile technique by the actors posing as surgeons and nurses, and there were always plenty of them. The intimate conversations of the TV nurses and surgeons complete with voiceovers while in the OR were also a source of mocking amusement. Nancy tied up Tim’s gown after he had donned the gown and gloves. She left Tim to do the sterile set up, and went to the pre-op area to see the patient.

 The prisoner was in the isolation room, separate from the common area of pre-op, usually reserved for those patients coming to the OR with an infection or contagious condition. Upon entering the isolation room Nancy immediately saw the heavy shackles on the patients’ hands and feet, firmly binding him to the gurney. She advanced to the gurney, pulling up a chair so that she would be at eye level with the prisoner/patient. Nancy had given much thought as to how she would approach this patient interview. First of all, she had decided that she must think of him as Mike ______, not as the prisoner, or as the patient. Before she could initiate a greeting, Mike spoke up “Sorry about all the chains, I can see they spook you. The hell of it is, I would do things in other situations, but not now – I don’t want to f***k things up for my Ma. Life has been a real s**tstorm for her, being sick and all, so this is the thing I can do for her.” Nancy replied “Thank you for that Mike, my name is Nancy. I’ll be your nurse in the OR. Right now I need to confirm some of the information I got from your chart, and then ask you some questions.”

  Nancy started down her check list of innocuous seeming questions, almost all of which the patient would have been asked before. The repetition of the questions while annoying to the patient, was intentional. Nancy could not count the times that patients suddenly remembered something important when asked the same question for the fourth time. And as routine as the questions sounded, they all reflected matters that were matters of safety and even life or death. For example; “When was the last time you had something to eat or drink?” With the induction of anesthesia there was a very real risk of patients suddenly vomiting, which if any of the vomitus was aspirated, posed a very possibly lethal situation. Jimi Hendrix died from aspiration when he overdosed, a situation very much like the induction of anesthesia. Another routine question was “are you wearing contact lenses?” Anesthesia knocked out normal protective reflexes, so contact lenses left in the eyes during surgery could result in damage to the cornea, as there would be no eye blinks, or movement of the eyeball as in normal sleep or in an conscious state. Another question always asked was “Have you ever had anesthesia or any problems with anesthesia, or has anyone in your family ever had a problem with anesthesia?” This is because of Malignant Hyperthermia, an inherited defect of calcium metabolism which can be triggered by exposure to many of the most common anesthetic agents. There is no straightforward test or practical screening procedure for the condition. It occurs once in every fifty thousand to one hundred thousand cases. It is associated with a five to ten percent mortality rate. Nancy had seen it once in her career and never wanted to see it again.

   When she reached the end of her checklist she asked Mike if he had any questions as she always did. Mike’s question took her by surprise. Mike asked “What’s it like, going to sleep like that? I figure this is sort of a dress rehearsal for me.” Nancy paused for a moment, then looked him straight in the eye and said “I had anesthesia once. The anesthesiologist told me to pick out a good dream, I felt some cold moving up my arm from the IV and it was as if a switch was turned off. I woke up when it was over and there was just nothing in-between. The time I was out just didn’t exist for me. You are probably right about it being a dress rehearsal. I expect it will be almost exactly the same except that there will be no waking up.” Mike said matter-of-factly, “That’s about what I expected. Just nothing.” He seemed to appreciate the directness of Nancy’s answer to his question. Still looking him directly in the eye, Nancy said “I will be standing next to you during the induction of anesthesia. We will take good care of you while you are here.” Mike nodded. Nancy got up and left to return to the OR.

   Tim had completed setting up the sterile table. Nancy got the count sheets and the pair began counting the table. Sharps, such as blades, hypodermic needles and suture needles were counted in one category. Sponges and towels were counted in a second category. Then all the instruments were counted by type and name. Lastly all the small accessory items were counted. All would be counted again as the abdomen was closed, and a third time as the skin was stitched or as more commonly now, stapled. The point was to make sure that none of these items remained inside of the patient. A retained object was one of those things that was indefensible, an instant judgment against the surgeon and OR nurses. The legal term is “Ipso Facto”, meaning “by the fact itself” negligence has occurred. In cases of extreme urgency, when there is no time to count, X-rays are taken before leaving the OR. All the objects used in surgery are radiopaque, which means they show up on an x-ray. So even in those situations there is no defense. The counting complete, Nancy walked through the substerile room to the other OR, leaving Tim to mind the sterile table. Sterile tables are never left unattended, lest they be unknowingly contaminated.

   Nancy arrived just as Mike was brought in to the OR, still manacled to the gurney. Two prison guards accompanied him, and would be in the OR until he was unconscious, then they would remain just outside the doors until it was time to wake Mike up. The gurney was pulled up even with the OR table, the guards unlocked the shackles, Mile slid across to the OR table, and was once again shackled, this time to the table. The guards moved back, and Nancy took her place to the right of Mike’s head. Dr. Nelson, the anesthesiologist talked Mike through the steps in preparation for induction. Nancy helped to place the monitoring leads, and when all was complete, held the oxygen mask to Mike’s face to pre-oxygenate his blood, the last step before injection of Propofol, the induction agent. Nancy said to Mike “ Would you like me to hold your hand as you go off to sleep?” Mike swallowed hard and nodded to Nancy. She took his hand. Dr. Nelson said “OK, I’m injecting now, you may feel the drug gong up you arm. Some say its cold, some say it burns, but it will only last a couple of seconds.” Mike nodded again and Dr. Nelson injected the milky drug. In seconds Mike’s body visibly relaxed, and his eyes lost focus. Dr. Nelson squeezed the rubber bag a couple of times in quick succession, and removed the mask, tilted the head back, unfolded his laryngoscope and with a deft motion, placed in Mike’s mouth and down his throat. While he was doing this, Nancy drew the clear plastic endotracheal (ET) tube from its wrapper, attached a 10cc syringe filled with air to the small inflation line on the side of the ET tube, and held it in readiness. She felt just below Mike’s adamsapple for the cricoid cartilage, applying a gentile pressure. This caused the rigid cartilage to compress the esophagus, keeping the trachea open and the esophagus closed a precaution against aspiration and lessening the chance of a misplacement of the ET tube. When Dr. Nelson got a good view of the vocal cords, he held up his hand and Nancy placed the ET tube in his hand, properly oriented for insertion. With a skilled and practiced motion, Dr. Nelson pushed the ET tube through the vocal chords and into the trachea. Nancy gently but firmly pushed the plunger of the air filled syringe, inflating the balloon-like cuff at the end of the ET tube. The trachea was now sealed off from the esophagus, preventing any chance of aspiration. Dr. Nelson gave a squeeze again on the rubber bag, observed the rise of the chest, and as pressure was released, the condensation that appeared in the transparent ET tube. These confirmed to Dr. Nelson and Nancy that the tube was correctly placed in the trachea and not in the esophagus.

   Nancy held the doors so that Tim could bring the sterile table through the substerile room into the OR. The guard removed the shackles from Mike. Nancy placed a foley catheter into Mikes bladder, so that the urine output could be monitored. This was important because the first observable sign of hemodynamic instability (the interaction of blood volume and pressure) would be a decrease in urinary output. It would also be a direct indication of Mike’s kidney function. Nancy also placed SCD (sequential compression device) sleeves on Mike’s legs to prevent the formation of clots. If Mike formed clots in his legs, the least serious complication would be a DVT (deep vein thrombosis) which would require him to be on anticoagulants until the clots cleared, which could cause post-operative bleeding. More seriously, if clots formed and broke loose, Mike could suffer a PE (pulmonary embolism) a potentially fatal complication. Then she placed a grounding pad for the elctrocautery, more commonly called a Bovie, which would protect Mike from electrical burns from the electrocautery. Lastly she painted Mike’s abdomen with gluteraldehyde solution to disinfect the skin. While Nancy was occupied, Tim gowned and gloved Dr. Moatz, and his transplant fellow, Dr. Ted Farrand. The trio of sterilely gowned and gloved team members then draped Mike. Tables were moved into position, Tim Passed the scalpel to Dr. Moatz, and the incision was made.


   About an hour and a half later, Dr. Moatz took the kidney to the sterile table, flushed it with Wisconsin University Solution, a mix of nutrients and electrolytes, placed it into a sterile plastic bag, and then into a sterile plastic jar. He handed it off to Nancy, who placed it into a Styrofoam container full of ice, which in turn went into a foil lined corrugated box. She attached all the relevant records and certifications that she had completed in a pocket on the side of the corrugated box, and a duplicate set inside. Until recently swing top Playmate coolers had been the transport container of choice. Thus packaged, there was about an eight hour window for transplant of the kidney, but the sooner the transplant, the better. Dr. Moatz checked to see that all was well with the closure which he left to Dr. Farrand, stepped back from the sterile field, and pulled off his gown and gloves. He took the precious package and left the OR, already on his cell phone to alert the waiting team with Mike’s mother that he was en route with the kidney.

   The closure of the wound was uneventful, Nancy and Tim completed their counts which were correct, and mike was moved from the OR table to the gurney while still asleep and entubated, a departure from the normal procedure which was to wake a patient up and extubate (remove the ET tube) while still on the OR table. In this case, the move was made first to enable the guard to shackle Mike before he awoke. As Mike began to stir, the extubation was smoothly accomplished. Shortly mike became conscious, looked about and grunted “S***t, I’m still here”. In his groggy half alert state he was taken to the PACU, and Nancy and Tim paged for housekeeping and began the process of turning the room over for their next case, a routine Inguinal Hernia Repair. The excitement was over, and they were instantly plunged back into the routine of a busy day.

   About two in the afternoon, another nurse came into the OR and relived Nancy, with instructions for Nancy to go to Chicky’s office. Nancy gave her report and went to the office expecting that it had something to do with the harvest. Entering the office, she saw a uniformed officer and then the pale look on Chicky’s face. Her knees felt suddenly weak. The officer grabbed her and eased her into a chair. “I am very sorry to tell you this” he said, “but your husband was struck by a car while he was making a traffic stop. He was killed instantly.” The officer and Chicky allowed Nancy a moment for the news to sink in. Chicky asked if there was anyone she could call for Nancy. She shook her head side to side. The officer said “We are here to take you home, another officer will take care of your car. The chaplain will be at your home by the time we get there.” He helped Nancy to stand a tenderly took her arm and led her from the office.

2 comments:

Anonymous said...

Wow!
Truly a great post,I love the vivid stories he tells

Debs said...

I really liked the way you explained the terminology that is used. The stories were great. I can't wait til the next chapter.