Saturday, March 06, 2010

Two stories, two songs, one bottle of wine.

This is not something you're going to hear a lot of people say, but I love free flaps.

(For the non-medical folks, a "free flap" is where a chunk of fat, skin, and blood vessels is hacked off of one part of the body and sewn onto another. Okay, maybe not "hacked", but it looks pretty awful for the first couple of days. Anyway.)

Free flaps are what our plastic surgeons use when they have to take half of somebody's face off, usually due to skin cancer. Squamous cell carcinoma is the culprit in these cases (see your dermatologist regularly!) and the patients are mostly men in their 70's. Flaps usually come from either the chest or thigh, and they're put in very, very carefully, with all the arteries and veins reanastamosed and zillions of tiny stitches everywhere, along with the faded ink of the sterile markers the surgeons use to outline the donor site. It's way cool. Trust me.

Anyhow, you have to check the pulses in these flaps every hour for the first two or three days, to make sure that it's getting blood. That means you get to know your patient pretty well, as you're in there waking him up every hour.

I got lucky. My patient was a thoroughly charming man, a retired musician and orchestra conductor, and we got along famously. He was extremely good-natured about being awakened every hour or so for pulse checks (you use a Doppler machine for that, and it's like Christmas every time you hear the whoosh-whoosh of a good pulse). We talked music and politics and discovered that we both are seriously annoyed by Garrison Keillor, except for his joke show.

Which led to a joke-off. I think I won; I told him the joke about the Australian explorer, tea shop, and koala bear that I've only told to four people before in my whole life. The punchline's kind of obscure, so I approach the joke with trepidation if I'm not totally sure of the audience. He told me the one about Eve being created with three breasts; I told him the one about the baby seal walking into the bar. He recounted the story of the two blondes on opposite sides of a river; I rejoined with the question of what to do with an elephant with three balls. It was a good night. He went home late this week, just in time to catch the annual joke show on PRI.

And so, a very pretty song with a weird set of lyrics.

Graft-versus-host disease is not something you ever, ever want to see.

Especially not in a young woman who's gotten a bone marrow transplant from a related donor, in whom everything should've gone fine, except for the weird viral infection she somehow picked up while at Holy Kamole.

GVH (again, for the non-medical folks) is what happens when you get a bone marrow transplant--or really, any transplant--from another person. The transplant itself has a more robust immune response than the body into which it's transplanted, so the transplant starts to reject the body. Essentially, it's the opposite of what happens if your body rejects a transplant: the transplant goes crazy and starts rejecting *you*, and it's truly awful.

Seriously: in the world of Do Not Want, this is up near the top.

I knew something was going awry when I saw that the palms of her hands and the soles of her feet had turned bright red and the skin had begun to slough off. That's the first sign: your skin sloughs off. At the same time, your *insides* are sloughing off, too, leading to things like diarrhea that can be measured in multiples of liters per day. This particular patient was already intubated, so thank God we didn't have to try that, with no platelets and no immune system and an already-friable trachea.

She was my patient for three days. Everything that could possibly go wrong with her did. I transfused platelets until the blood bank was reluctant to give me any more; she was using up the whole hospital complex's supply. I ran steroids IV, in an attempt to suppress the immune response that was eating her alive. She yanked the oxygen supply off her ET tube, so I reconnected her and started her on propofol (what the OR guys call "The MJ") in an attempt to keep her down so she wouldn't have to work to breathe. I transfused blood when it became apparent that the whacked-out immune response of her transplant was eating up red cells.

Eventually, I connected what is delicately called a "fecal containment device" to a three-liter drip bag, and only had to empty it twice during a twelve-hour shift.

She was fifteen years younger than I am.

It became clear that there was nothing in the world we could do for her. Her sister, her only living relative, gave the go-ahead for us to take out the tube. She couldn't be in the room, because she was pregnant, and some of the drugs we were using are not good for pregnant women to be around, so I was the only one with my patient.

She died very peacefully. I broke every rule in the book and took off all my isolation gear, took off my gloves, and cuddled her as she finished breathing. There wasn't, strangely enough, any struggle. She didn't fight to breathe; I think she knew it was done.

Her sister, the one who'd donated the marrow that ended up killing her, watched us through the window. After it was all over, she told me, "I used to always call my mom or my sister twice a week. Now I can't call either one of them." She walked away. Her eyes were blank, but dry.

So, Kaylee, this one is for you. I would change the last line of the last verse if I could.


geena said...

There's a national shortage of Propofol. We've been having to use Fentanyl and Versed drips.

Can you score me some Dip on the black market? :) :)

bobbie said...

Bless, bless, bless you for breaking protocol and holding her ~ a truly angelic being you are ~~~

Kimberly said...

How very, very fortunate she was to have you there with her at the end. As so many others have been lucky to have you at their bedside, like your orchestra conductor above. I love reading your blog...was finally accepted to nursing school (well, a couple of them) a few weeks ago and will start in June, a couple months shy of age 41. I'm going into a totally different specialty, but aside from your amazing writing and your dog and house stories (which I also enjoy)-- I love coming here and seeing how it can be done. Thanks for giving us a window on it all.

Penny Mitchell said...

I love you. Thank you for being there for her.

woolywoman said...

you are a fine woman, a fine nurse, and i raise my glass to you.

Maha said...

How awful for both sisters. I couldn't imagine if that happened to my sister. In situations like these, protocol needs to be broken.

Celeste said...

Absolutely heartbreaking. Who takes care of the caretakers?

Mary said...

I lost my sister to GVHD and though her suffering was much more prolonged and took place over six years, your description is spot on. God bless you for easing your patient's transition from this life. And I'm not a God bless you sort of person normally, but that was an exceptionally loving thing to do.

Jo said...

I should point out, in response to the folks who are thanking me for breaking protocol, that I really *didn't*. The isolation gear was there to protect the patient, not anybody else (the virus she had was not a threat to anyone who wasn't severely immunocompromised), so taking it off wouldn't, at that point, do her any harm.

It's been a rough week. Thanks for your supportive words.

Anonymous said...

You are the kind of person I would hope would be with me were I that terribly ill. Well done Jo.

messymimi said...

May your reward in heaven be great.

Thank you for choosing to be a nurse.

Anonymous said...

Am I the only one who went to the comments to see if you were going to tell us those jokes?



Charles Chandler said...

What is Garison Keillor doing to annoy you?

Also, seconding the request for the Austrailian Explorer joke. I'll post the knock-knock that caused me (and me alone, in a room of 30 geeks) to guffaw upon hearing it as a trade.

Finally, is that from Peter Gabriel's new album of covers? I was surprised (pleasantly) to find that was a cover of the Magnetic Fields.

Jo said...

Okay, okay. Jokes: (and yes, that is off PG's new album of covers, "Scratch My Back." I can't wait until the artists he's covered cover his songs on an album they're calling "I'll Scratch Yours.")

An Australian explorer spent several months in the Outback. Finally, exhausted and desperately wanting a cup of tea, he wandered into Merzy, a small town by the river of the same name. Stepping into a tea shop, he called for a pot of tea, which was quickly delivered by the waiter.

The explorer was amazed. This was the best tea he'd ever had. He begged to be taken to the chef so that he could pay his compliments in person.

The waiter led him into a steamy kitchen, where he saw the chef, standing before a large pot of tea. The chef was slowly dipping a koala bear in a bamboo cage into the tea.

Aghast, the explorer said, "Isn't that a bit unsanitary, what with all the hair in the tea? Shouldn't you strain it before it's served?"

The chef drew himself up to his full height and said, "Sir! The koala-tea of Merzy is *not* strained!"



Who's there?
Elvis who?
How quickly they forget.

katie hanson said...

i love your posts like this. and i hate your posts like this. they wake me up a bit, make me realize what's important, how absolutely great i have it and that i should not be complaining about anything.

your blog is where i come when i want to read something that will evoke maniacal laughter. and when i want to read something that will smack me on the head and shift my worldview a little.

thanks, jo.