If I Only Had a Brain

I am about to attempt to tell you a work story.  It is a story which could be very complicated and difficult to portray if you aren't a part of the medical field.  But if you will just suffer through and try to see my sheer idiocy, I think you will appreciate it.

This week we have been taking care of a lady who has been in the icu for over two weeks now.  She suffered a hemmorhagic stroke and the neurosurgeon went in to clip the bleed. After surgery she was completely unresponsive.  No reflexes noted.  Her eyes are open but they jerk around, never really seeing anything.  She is on a ventilator, and she initiates breath, but is unable to fully breathe on her own. Her heart is stable.  She has a giant tube coming out the top of her head to drain the excess fluid off, and she has a pressure sensor in there to monitor her intracranial pressure (referred to ICP from this point on.)  She also has staples across half of her head where they went in to do the surgery on her brain.  Her feet and hands are cold and mottled, and her limbs are limp with no muscle tone response noted when you move or reposition her.

This is all very horrific sounding, I know.  It is horrific. Especially when you factor in that the patient's family is English as a second language, and they keep thinking she's going to get better.  I don't see how she's going to get better after two weeks of no response, but I'm not God and that's not my decision to make.  Instead, I just feel terrible for them.

Here's a news flash for you:  I hate  brains.  I love things to do with the heart and cardiovascular system.  I get it.  I specialized in it right out of school, and while neurologic issues have never been completely unavoidable, since I've been in my current job they have been few and far between.  Imagine my joy when I realized on Monday that I was going to have to bring this patient from the intensive care unit to our department and monitor her while the doctor did a cerebral angiogram, which is basically a study of the vessels in her brain.  I got a quick and dirty inservice from the patient's nurse about her drains and what they meant, and especially that her ICP must not get above 20, and her drain needed to stay at the level of her ear.  If the drain was repositioned during transport and was above her ear, it wouldn't drain.  Too far below the ear, and it would drain too fast.

How do I spell stress?  B-R-A-I-N.

Monday we did the procedure with no hitches.  We injected some medicine directly into her brain that was supposed to improve blood flow to her brain. I was annoyed to learn that we would be bringing her back daily until she gets better.  

So we had to bring her back on Tuesday.  On Tuesday I went with one of my nurse friends for our department, and we had agreed to tag team her. I was feeling pretty okay with it, as the previous day had gone fine.

Well, of course by the time I moved her to our table and got my monitor hooked up, and the respiratory therapist put her on a portable ventilator, her ICP had climbed to 28.  "Well crap."  But then as I looked through her chart I realized that it said to notify the doctor if the ICP stayed up more than 10 minutes.  So I waited a bit.

Her ICP didn't budge...I lowered the drain...it still didn't budge, nor did it begin to drain.  I started to sweat.  Profusely.  I was so glad I had another nurse assisting me, and our plan was for her to stay with the patient and do basic care, and I would fetch anything she needed, or call the ICU nurse if she had a question, or whatever needed done...

I paged the neurosurgeon, Dr. X.  We will call him Dr. X as his last name has no less than 11 letters and like 5 syllables, and even after talking to him like twenty times I am still not sure how to pronounce it.

So, Dr. X calls back.  I inform him of her ICP, her blood pressure, her heart rate, her oxygen levels, and I even was able to tell him what her medications were running at.  I was mentally patting myself on the back for having facts, even as I felt sweat trickling between my shoulder blades.

"What is her ventriculostomy pressure?"

Now, this doctor has a pretty strong accent.  I was pretty sure I'd misheard him.  Because it sounded like he said ventriculostomy, and I was pretty sure no such word existed...So, I said, "Excuse me?"

"Ventriculostomy pressure.  What is it?"

"I'm sorry.  I can understand ventricul something or other, but that is all."

"Ventriculostomy.   Ventriculostomy.  Ventriculostomy.  What is the pressure reading on it?"

Okay.  So he DEFINITELY said ventriculostomy.  Which I still felt pretty sure was not a real word.  "I'm sorry sir, but I'm not sure what you mean by that."  I'm pretty sure that instilled all sorts of confidence in my roll as this patient's care giver.

"On the monitor, what does it say her ventriculostomy pressure is?"  Okay.  He just keeps saying the same thing over and over.  Apparently it's real.  And he expects me to know what it is, and what to do about it.

Crapola.

"Sir, I'm sorry, but the only pressure reading I have is off of the Camino, and it says her ICP is 28."

"But there is another monitor coming out of her head.  Do you see it?"

WHAT???? 

"No sir.  I only see the Camino pressure monitor and her drain.  I will call the ICU nurse to come show me what to do."

"Wait a minute.  Aren't you a nurse?"

"Yes sir.  I'm a nurse, but to be honest I'm a PROCEDURAL nurse, and while I had Scott give me a quick and dirty report on how to care for this patient, he never said the word ventriculostomy to me."

He then informed me that he had ordered her drain clamped, and that the ICP had probably raised due to the stress of moving, and I simply needed to open the ventriculostomy during the procedure and leave it open for one hour after...

There was that darn WORD again.

So I called the ICU nurse.  And it turns out that the ventriculostomy is the drain that I was calling a DRAIN.  Because that is what the simple folk call a drain for your brain...a drain.  He showed me that he had clamped the drain off the day before, so no matter how low I moved the drain, it wasn't going to lower her ICP.  Oh did I mention that I all but put that drain on the floor trying to drop her ICP?  Did I mention that by this point my scrubs were soaked in sweat under my lead apron?  I told my nurse friend that while I felt incredibly stupid, at least I'd probably never have to meet Dr. X face to face.

Well we opened the drain, and low and behold the ICP dropped to the normal range, and we were able to complete our procedure.  After we finished up Dr. X, the neurosurgeon showed up...At least I guessed it was him.  He was in a doctor's coat, and he was unfamiliar to me.  I could totally tell he was looking for me.  I decided to take the bull by the horns.

"Hi!  Are you Dr. X?"  Sound cheerful and nonchalantly confident Andi.  Then he will decide that while you may be a ditz at least you're friendly...

"Yes, I am."

"I'm Andi.  I was the nurse on the phone with you earlier.  I'm so sorry for the misunderstanding earlier.  I don't want you to think we don't know what we're doing here.  Except I have never dealt with one of these before.  So I guess that means I really don't."  And I smiled my most winning smile and I gave a little lighthearted chuckle.  Could you just shut up?  Why must you blabber on when you are nervous?  Or happy?  Or sad? 

"No problem. I'm sorry too. I thought I was speaking with the ICU nurse, so I was wondering how you didn't know what the monitors were for."

I was so relieved that he wasn't angry, and surprisingly nice but still relatively sure he thought I was a nincompoop...I decided fleeing was the smart thing to do in this situation...I gently lead him to our control room where I introduced him to our doctor, and headed back to the intensive care with the patient. 

Of course I ran into Dr. X again before I was gone.

Blast it all!  Must this man suddenly be everywhere I have to be?

And I began to blush and sweat even more profusely than I already was..."Hi!" I decided to keep up my light and friendly facade.  It wouldn't do at all for him to realize I never wanted to see him again.

"Hello.  I wanted to apologize about not realizing where you were earlier..." And he proceeded to take me back to the patient bedside and explain that the ventriculostomy pressure was monitored by a bedside monitor in the ICU, so I really could not have told him that reading as the monitor wasn't with me.  And he took the time to explain things to me in a much better detail than the nurse had.  And I was able to understand him easier face to face.

That made me feel much better.

And a little bit less of an idiot.

However, I still hate brains...

On a more positive note, I found out that as of January first two neuro interventionalists will be coming to work in our department, and that all of us have to go through special training to know how to care for brain injury patients.  I can only begin to guess the sort of ego that comes with a person who is willing to work on brains by inserting a catheter into the artery in your groin and working their way to the brain...And I can only guess this will lead to more interaction with Dr. X...

Oh, wait.  That is actually TERRIBLE news.  Blast it all.