Candle lady is now intubated and on dialysis

[whitewriter]

Just when I thought that she would be back on the ward before I returned from days off,

I was allocated Bed 24 or aka. the lady who gave me the candle.

Just like the fate of so many who are admitted from the ward to ICU, they tend to get much worse before they get better. After all, there is always a
reason for admission (deterioration) and that means worse, not better.

She was intubated and ventilated for a pH of 7.14 and commenced onto CRRT or continuous renal replacement therapy (ICU dialysis).

Dialysis is something we do a lot of at MSH. Maybe because we are a liver transplant hospital.
Maybe because we get a lot of multi organ failure.

Apparently it's not much done in other ICUs. Such that when you have dialysis over there, it's like your the shit for the day. If you have ECMO your the new King.

Here it's just another day.

Would I have liked my first dialysis to be on a day shift with the educator next to me? Yes.

But if anything somehow this was a super simple circut (heparin/protamine) and was already set up and fresh (so likely could last the whole shift without me needing to change the circut)--- which it did.
and it was running slow so the bags didn't need to be changed too frequently.

It was line change night for this lady, however.
The last time I did a line change was about 2 years ago?

She was fairly simple. No prop, no fent. Just precedex, insulin, fair wack of norad.

I chose not to double pump the norad because I realised that of all my lumens (precedex, insulin and norad) none of them could be flushed, without breaking the rule of "these are all drugs that you don't bolus"
and that the spare lumen was the CVP lumen, and I didn't want to end up with norad on that lumen- because that should be reserved for CVP and drugs.

Whats double pumping?

Double pumping is when you want to change the bung on the line (which is part of line change: you don't just change the lines, your supposed to also change all the bungs) -
So what you do, is you have 1 empty lumen. You change the bung. Then you connect up the new line and the new bag of noradrenaline, and you start turning it up. Start at like 1ml/hr. Then you slowly increase to 2 maybe, and wait.
The old line and the old bag of norad is running at whatever you had it at , say 10mls/hr - you watch the blood pressure, and see how it rises (as now the pt is technically on 11 ml/hr of norad) As soon as the blood pressure starts to rise, you turn the old norad down. 1 ml at a time, and increase the new norad as well, 1 ml at a time. Until eventually the old norad is turned off -- and the new line is running your norad.

Now you can aspirate the old line and flush it and have it clear for another drug.

I didn't really want to aspirate and flush the precedex to double pump onto there, because then she would have no sedation and I'd have an aggitated intubated pt whilst doing line change: no thanks.

I didn't really want to do that to insulin either because we'd already lost control of the BGLs today, and I'd be left with who knows how long until the insulin filled the new line again, if I aspirated it and swapped it to another lumen.

So I did the face switch-a-roo and called it a day.

The biggest fear was when the protamine syringe was due and I had somehow attached a line to it even though it didn't need a new line (because it was off the vascath and it was CVC change night not vascath change night: come to think of it when would the protamine line be changed? I have no idea...) and I had this sudden fear that somehow I had swapped the insulin syringe or the precedex syringe with the protamine
since they all look the same (except they have different words on their labels that I hand wrote).

Protamine is there to reverse the heparin from the dialysis circuit so if I got it confused it would have devastating impact on her coagulation (she would be well over coagulated) and could be bleeding internally.

I did a full set of daily bloods not long after and her INR remained stable so I was reassured that I hadn't accidentally swapped the syringes. Plus she remained calm and her blood sugars were in range - so all the syringes were correct.

Yes that is a mistake that has been made before.

The night went okay and in the morning; I handed over to a senior that has become senior in the 2 years that I left - and she was doing supernumary buddy with a brand new IP.


It's that time of year again (happens about 3 times a year) we get fresh new staff.





I came again tonight to babysit Bed 24 for 2 hours until the overtimer came.

If you do overtime at MSH ICU, we always give you the easiest patient. Bed 24 on a fresh circut was the easiest.

She went okay during the day, only that they were still searching for the source of the multi organ failure. ICU were getting frustrated the surgeons didn't seem to want to operate due to her sepsis (line sepsis, and sepsis from the diverticulitis that was incidentally found whilst I was away and left her with both an open abdomen and a stoma formation). They stabbed in the dark, maybe on the CT scan they saw something in her uterus/ovaries? -- teratoma maybe. So they called for a transvaginal ultrasound. They didn't find the answer from that scan either.

Still don't know why she's got multiorgan failure.

After I handed her over I shuffled over to bed 28 (ECR) and Bed 29 (old grandpa with encephalitis and alcoholic related disease)
They're like two peas in a pod.
both GCS 12
Bed 28 due to the stroke. Apparently she kayak's daily on her waterfront property.
Reminds me of my ex. And how his family had a waterfront property. Ah the things I gave up.
Bed 29 due to encephalitis. He's mumbling in jumbled Arabic and English - sounds like he's making words but none make sense. Or so says the security gaurd who can speak Arabic whose with him 24/7 because he's had so many code black's called on him he's become a danger to staff. Something about a knife at one stage?

I'm partnered with a senior nurse whom there was an email sent around recently - that his adult son has recently passed away. By recently I mean 2 weeks ago. I don't know if he's been sick for a while (I think he has been, based on what I've heard) but I really didn't expect to seem him back on the foor so soon.



Isn't it nuts that technically today is my day off (the 18th) but that I have to work until 8am on my day off because this nightshift technically belongs to the 17th?