Saturday, January 21, 2006
I see you
The past two nights I had an "off-service" patient in the ICU, meaning she wasn't an oncology or stem cell transplant patient, she just came to our unit probably because the other ICUs were full. She was 24, and came to the hospital for a complicated abdominal surgery. She sailed through that, then her dialysis fistula (surgical permanent graft between blood vessels in the arm used for kidney dialysis) clotted off, so she had to go to Interventional Radiology where they were going to try to bust out the clot with a balloon threaded through her artery. Well, that failed so they kept her in IR to insert a temporary dialysis catheter into a vein through her chest well. I know, blah blah, medcakes. Just a little background. BUT...the night before going to IR, her potassium level was pretty high, probably because she hadn't had dialysis (see fistula clotting off...). To bring it back down, she was given a large dose of insulin (insulin drives potassium back into the cells, thus lowering potassium levels in the blood). And in order to combat this large dose of insulin, she also got some D50 (big dose of dextrose) to avoid dropping her blood sugar level. Well, apparently, this didn't work too well, so they repeated this procedure the following morning, then sent her on down to IR where she got large doses of fentanyl (narcotic) and versed (sedative). I know, my astute readers, even if you're not in the medical profession, you are wondering, did anyone check her blood sugar in the midst of all this insulin and dextrose? Apparently not. So our little patient went happily to sleep in IR while they poked about with catheters and the like, and when all that was done, seemed to be taking her sweet time waking back up. Actually, she didn't wake back up. So her nurse called a "code", gave her lots of narcan (reverses the effects of narcotics, really pisses off drug addicts when you administer it in the ER, but that's a completely different story) which had no effect, and a doctor began bagging her (administering oxygen with a mask and bag, just like on ER!). Finally someone checked a blood sugar level, it was 35. That's really darn low. Me and you and Sue over there are probably around 80 to 120 most of the time, and that's good. Below 50 and you might fall asleep, or go into a coma. Your brain eats glucose for energy and food, and nothing else, so it gets pretty pissed off when there's no food. And if you're following the timeline of the story, you might be realizing that our little patient could have had such a low blood sugar for g*d knows how long. If you're even more astute, or a nephrologist, you will also realize that our patient is in chronic renal failure (dialysis, fistula, etc). And how does the body get rid of insulin? Through the kidneys. But what if the kidneys don't work? Insulin hangs around. And like Pac Man, just zips its way through the blood, chomping happily through every bit of glucose in its way. So we'd give her dextrose, her sugars came up briefly, then within a few hours, she bottom out again.
Following her "code," the patient, I'll call her Katie, was transferred to the ICU which is where I met her. Her family and friends were at her bedside, tearful and worried. Katie was awake, staring off into space. She looked tiny in the big bed, with long hair, huge blue eyes, she looked 12. She wouldn't track, make eye contact, follow commands, or communicate. She was fairly restless and agitated. The nurse giving me report explained her current neuro status, as well as her extensive medical history. As he ran down the list of the neuro assessment, I asked, "Well, what's her baseline? What do I have to compare to for improvement?"
"Her baseline? Well, last week she was working at Starbucks. That's her baseline."
The nephrologist examined her later following dialysis then spoke to me in lowered tones in the hallway. "What I'm really afraid of, which is really possible, is that the damage is permanent," she confided. By the morning, Katie was tracking better, and much calmer, but hadn't spoken a word. She responded to questions simply by nodding, but she nodded to everything. Her best friend stood at her bedside, talking to her, "Dude, you need to talk to me," she said half-joking, as her voice quivered.
Anyway, I came back the next night, and Katie was sitting up in bed, surrounded by friends, trashy magazines, and stuffed animals. "That was freaky!" she laughed. "Hypoglycemic coma and shock SUCKS!"
Sometimes they get do get better.