As I've indicated, I work in a combined CCU/ICU and so there are times when I have to take care of people who have heart issues as their main issue. That's what I got to take care of one shift, I started out with a completely different assignment but because of my workplace accomodation, didn't have to remain on that assignment and was traded for someone else's. I ended up with a little old lady (LOL), a 96 yr old gal who had a NSTEMI - perfectly stable thankfully. More of a watch and see. She just wanted to be medically managed and be made better. That's what she got in the end.
My other bed was empty at the beginning of the shift but I was told that I would be getting a new admit from the ER. Another NSTEMI but with an extensive cardiac history and was on chemo for some kind of cancer that metasticized elsewhere. Never a good thing. Chemo is HARD on the body I say, and of course that also takes a toll on the heart.
He was a sweet old sole. When I first met him, in the first 10 minutes became significantly unstable. I spent my entire shift on the phone calling the most responsible physician (MRP) for orders or follow up - this that and the other thing. I felt like I was calling them constantly. All for good reasons too. Turns out that ER didn't bother to tell me that this fellow had an inferior MI and the good ER docs went and ordered Nitro and morphine for my fellow. Now this is VITAL information for a person who is to take care of ppl like these. Shame on me for not asking really. I figured this type of info a person would readily share with someone else. But nope....
When I got report from the ER nurse I was advised that she had given Nitro and my fellow's chest pain (CP) had been relieved with this. So when he came to me complaining of CP again, I went and did what my previous counterpart did and give Nitro. Well if I had been told about the inferior bit I certainly wouldn't have done this! It did as expected and relieved his CP but also sent him into cardiogenic shock. So I spent the rest of my shift trying to keep him alive because of the unintended consequence of this action.
What should have happened was that they should have taken him straight to our sister hospital and figured out his heart issues and tried to help him. But they said no so we had to hold on to him until morning when the cardiologist could force sister hospital to take him. Which happened and so I started shift two with him post transfer from sister hospital - being told that his 5 vessel CABG done almost 20 yrs ago had basically all clotted off and his heart was pooched. There wasn't anything they could do and stopped their PCI and sent him back to us.
So sad to come on shift to a sweet fellow and hear that there wasn't anything they could do for him. Kick in the pants I tell ya. So I went in to my patient, and had a frank heart to heart with him about what HE wanted. I asked him if the guys at the sister hospital had told him what they found, they did thankfully and so I asked him what he wanted out of all this. He understood that his life was in jeopardy, even if he did survive this current event. He told me that he just wanted to spend more time with his family. He was a father of three and still married. He indicated that if he could just get another month or two, that was all he wanted.
So I spent the rest of my shift, trying to make him comfortable and trying to prolong his life as best we could. I made it to the end of my shift and when I came back on he was still in my CCU. So another shift was started together.
I started this new shift in good spirits, he was requiring less heart support than when I had left and things were looking up. During the day shift I guess the Docs had a good discussion with him, after I had laid some seeds about CPR and intubation - that would he really want to pass with us pounding on an already impaired heart? That it wouldn't be a good death and he would still end up dying likely. So I was happy to see that post discussion with the Docs that he had decided a NO CPR/Dfib/Intubation for his care. I think he made the right decision, certainly for him anyways.
In the middle of the night things turned south though. Of course it all happened just as I was coming back from break He began to have ischemic events and his heart rhythm changed as did his BP - requiring more support to support it. I called the MRP and advised them and they came to assess him. I started him again on an antirhythmic and bolused him twice, hoping that he would convert. We kept at it for several hours and he did come out of the atrial flutter into atrial fibrilation but not for long unfortunately. I let the MRP know of this and she indicated that she would have to come perform a cardioversion. I let her know that I wasn't sure his heart would survive it, given that he's so clotted everywhere and he's having ischemic events right now and going into poor rhythms - ones that really are unsustainable.
So we decided together that we would call in his family and let them be together. I had to seek out approval for this because of the pandemic and no visitors are allowed unless death is expected. And although my fellow wasn't actively dying it wasn't expected that he would survive. And who knew if he even could survive with or without the cardioversion.
I had a frank conversation with my patient again about the impact of cardioversion - how it hurts like hell (don't know it personally but professionally) and we don't even know if it will improve his chances of survival. So he asked if he could speak with the MRP to ask this. Shockingly the MRP put this task onto another Doc - saying that it should be the cardiologist who has this conversation with him. But of course I find out after the fact that the MRP who said this IS a cardiologist herself!!!! That's what happens when you're too new and don't know everyone! So when I left my final rotation shift, my patient was still on the antirhythmic and requiring a cardioversion but wanting to speak with the Dr.
I came back several days to find out that when the Docs did go and talk to him he decided to not take the cardioversion and decided that he would live out his final days with his family surrounding him. I found out that this, however, took several days to come to fruit because palliative care Docs wouldn't take responsibility until pushed to.
But at least he got to palliative care and can spend the rest of his days surrounded by his family - the way he wanted it.
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