Tuesday, January 2, 2007

The Ultimate Christmas Gift

I spent my final shift of the year keeping a brain dead organ donor alive so that his organs would remain viable for transplantation. If you have never cared for one of these patients, I am here to tell you that they usually require more work than even very ill ICU patients. In fact, ask any ICU nurse who has cared for a donor patient, and they will likely tell you that these patients require 1:1 care.

Let me give you a little background on B (not his real initial, of course). He was a vibrant, intelligent man of 51 years who never made it home from midnight mass on Christmas. He was pulled over for suspected drunk driving when, in fact, he was in the middle of a massive stroke. The police recognized this and immediately summoned EMS. But it was all for naught. He was well within the 3 hour limit for tPA when he arrived in the ER at Work. But nooooo. They were "too busy" with all the drunks to give him the attention that he needed. In fact, he didn't even get heparin (never mind tPA) until about 8 hours later. As a result, by the time he arrived in the ICU, he had complete left hemiparesis and aphasia. He could, however, communicate his needs pretty well. I wish there was a way that I could ethically and in good conscience tell B's family that they should file suit against Work, because I think that the ER was grossly negligent and his death could have been avoided.

When I cared for him 2 nights after his admission, he began the swift downward spiral. When I arrived for my shift , his GCS was 13. When I left at the end of my shift, it was 3 - the worst a person can have. We intubated him at the very end of my 16 hour overnight shift. About 2 hours after that, he was declared brain dead. As is Work's protocol, the bedside nurse calls our regional organ procurement organization, and they are the ones who approach the family about donation. It took B's family almost a whole day to decide to donate. For some families, it's an easy decision and for others, it's gut-wrenching. It wasn't easy for this family.

The care of donors is extremely involved. Placement of arterial and CVC lines if not already in place. Hourly vitals and suctioning. Chest Xray and hypo/hyperthermia blanket as indicated. STRICT hourly I & O, with cc for cc + 50 cc replacement IV fluids for urine output - e.g. 250 cc urine out = 300 cc IVF in the next hour. Initial set of labs (22 tubes PLUS 2 sets of blood cultures, sputum and urine cultures). Of course, pulling all that blood necessitated an increase in his Dopamine dose. Then, every 4 hour labs and ABG's. BP was maintained with Dopamine titrate and phenylephrine at a steady 25 mcg per minute. THEN .... any other meds or treatments as indicated by the q 4 hr labs ... like amps of bicarb here and there, mannitol here and there, insulin and calcium chloride now and then. It almost seems ridiculous to do all of this for a dead person. We needed to keep the organs as viable as possible. Intellectually, I understand the need for the rigamarole, but emotionally, it's hard.

It was with mixed emotions that I helped roll B to the OR for his organ harvesting. It felt like I was taking him to the gallows for an execution, and I had to keep reminding myself that he was already dead. I also had to keep reminding myself that many people would benefit from this tragedy. He had become a liver, kidney, pancreas, and heart valve donor. It is a very rewarding experience ... one that I hope all of you can experience at least once during your career.

I went home physically and emotionally exhausted, but after all was said and done, it would be a Merry Christmas for at least 5 families after all.



scalpel said...

Heparin for stroke is a fad that seems to come and go, and tPA is no guarantee either. Neither are iron-clad standards of care imo.

Runs With Scissors said...

True ... but is doing nothing a standard of care?

Judy said...

Thanks for writing this.

Presently, a childhood friend of my adult children is being kept alive until his organs are harvested.


I remembered having read this post, and it has been helpful to reread it at this time.

Thank you for what you do. And for doing it with such grace.