Three shifts with the one patient in ICU.
Lives the other side of the train station in my suburb.
ex-covid, now battling both sides of the coin: covid pneumonitis and an ICH.
The ICH is hypothesised to be due to either:
the high dose heparin required for the ecmo to get over the covid
or
some clot, also related to the ecmo circut.
It's an ICH, though. Not a hemorrhagic transformation-- although, can you tell on a CT scan the difference, they're both bleeds.
The kicker was that they discovered the bleed sort of late. He was ventilated the whole time( tracheostomyed about 2 weeks prior) and the GCS was persistently crap - it was at best a 5 and went to a 3 and then a week ish later they went for scan, and at the last minute changed it to a pan scan (whole body, not just lungs or abdo ) and hence forth found the ICH
Neurosurgery involvement -
and they did an evac of the clot, put the bone back (craniotomy) and threw in an EVD - and after some discussion decided that further surgical management would not be suitable. (terrible outcome assumed).
Medical management of the ICH ensued. Vent settings for neuroprotection with mandatory mode of ventilation chosen a RR of 32 aiming a normal CO2. I'm trying to remember if it was a pressure or volume controlled mode but I do remember his tidal volumes were 400s which is pretty normal and actually really good for someone with covid pneumonitis - where 100 is bad, 200 is good - and normal volumes is 6-8ml/kg. -
Paralysis + sedation, pupil checks + train of four to ensure adequate paralysis. He was a hard one to paralyse, you could see his thumb twitching with the TOF but the machine would declare 1/4 twitches.
I was unsure which to believe: the hand doing 3/4 (which means, inadequate) or the machine 1/4 (which is adequate). Things to research further. I followed the hand because who wants to be half paralysed and having a forced mode of ventilation at the same time.
EVD outputs hourly were fine and ICP okay.
SATURDAY - they wanted to wean the paralysis and see what his ICPs did. He started shivering (increased metabolic rate is bad for the brain) and his pupils had abnormal movement that I mistakenly classified as similar to dolls eye reflex (which is a feature of brain death testing actually cause I looked it up) but was just deviation. It looked horrid.
His sister was all over it - after being basically not involved for 2 months, due to it being "too hard" for his father to "see him like this" - (he was his father's carer and usually worked in retail however due to lockdowns was out of work for the meantime) - the ICH brought them back to see him.
Perhaps it was the nearing certainty of death rather than disability - as the family had told ICU that the pt would not want to live with a disability.
I wondered if his obesity (he was listed as 95kg for today but .. I'm 95 kg. I stared at him in the bed and wondered if we were actually the same weight and if I was deluding myself about my size) was affecting the paralysis (another thing to research) due to the meds being absorbed into his fat or muscle tissue and having irregular absorption -
anyhow.
So I'm looking at these swinging pupils and semi freaking out and the sister is like "that doesn't look good" and the consultant reviewed then said it's likely seizure like, and he's on anti epileptics anyways and the shivering is bad for the brain so lets just re-paralyse (and mask these terrible symptoms).
SUNDAY.
I'm allocated him again (ex-neuro ICU means everyone in small ICU think's I'm an expert handing the EVD when I haven't actually had a pt with an EVD for 2 years) and I start to realise general ICU is acopic regards the EVD. He remains sedated and paralysed throughout, todays' challenge are his bozo friends from the pub that turn up (I had advanced warning from the sister) who come to the bedside and sorta gently yell over his paralysed and mandatory ventilated body that he will "get better" and "come back and have a beer" and he's doing "Really well" (Cause his ICPs are stable... which we are forcing to be good btw. with that EVD and the paralysis and the sedation: the true test will be when we take these supports away) and here I am trying to explain its still "super early" and we take things almost an hour at a time - and that whilst the scan can say which section the bleed it is in, it won't say things like will he be able to drive or walk (or even drink water, let alone a beer, mind you - but I didn't mention that part).
His bozo friends were like "with all the medical technology you'd reckon they'd know more... "
Yeah buddy, that's why medicare is struggling - because they thought medical technology would fix more stuff (and it can but with more is more cost -- that we didn't budget for... Increased expectation, means you want better care -- these need to be planned for. Life is getting longer but that actually means, more expensive for the tax payer in regards to healthcare).
I didn't go there.
They thanked me for their care and after an hour of that (which delayed my lunch because I didn't quite want to leave him alone with them) - they left.
The day ended quietly.
MONDAY.
It's groundhog day. I'm back with him again.
I question, what if I made an error for the last 2 days. I've been handing over and teaching about the EVD on each handover (admittedly I also re-read the policy since it had been 2 yrs since I had an EVD). Apparently there isn't anyone else they want doing the EVD and he's considered terribly unwell and do you mind? Well no I don't but do you wanna put in someone else in there and I could be in the bedside next to him and I can assist and teach them so then someone else can learn? I thought it but it was too late -
plus I didn't know what the staffing skills mix was like across the floor, there could literally be no one else.
Monday means new consultant. A more experienced one this time who'd been a consultant since before I started and he wants.... to wean the paralysis and the sedation and just "See".
Actually, he wants to wean overnight. As long as the ICP is good, the shivering can continue and the eye deviation isn't an issue.
Weaning overnight is always horrible. You have registrars and residents who don't want to make decisions. They're on the mode of no rocking any boats: just set and sail. The nurses are on that pathway overnight too -- it's one of the things I miss about night shift.
On nightshift your main priorities are meds and obs and the wash. No scans are booked, no visits by allied health. No meals to be had, medications don't get changed. You might be angry cause the day staff forgot to arrange the supply of xyz medication that isn't ward stock, but beyond that: you set your GPS with coordinates and just work the shift.
Keep the pt clean tidy and happy. React to a few changes perhaps and hope nothing changes (like deterioration cause then reset occurs.
So I did the line change.
Because it was going to be due overnight, and I felt sorry for the nightstaff who had to wean the sedation overnight and watch the ICP and who knows how that would go, it could end up with an emergency scan (Actually I thought they wanted to scan him on Monday, but they changed it to Thursday to give him more of a chance which I agree with is a better plan).
Emergency scan AND line change would be too much for anyone.
Plus now I don't do night shifts means that I haven't done a line change in ages. So I did it cause I had time. And I like to do a nice ICU handover.
I left for 4 days off: and I guess I'll find out what happens to Mr bed 30 when I get back on Saturday.
Here's a kicker. I was on my tea break and the junior nurse watching got to talking with the sister and was like "look how bad he is, I wouldn't wish covid on my worst enemy" and the sister said, "Well, he's an anti-vaxxer so he sorta had it coming".
...
What does one say to that?!
We care for them all just the same.