As I was writing about liver failure a couple days ago, it crossed my mind that I was oversimplifying the issue. Kind of like this:

liver failure = death

liver transplant = life.

I don’t really think that way. I’ve definitely seen a spectrum when it comes to liver failure. It’s just that there is a certain point with the liver where it really can’t be turned around.

And just to illustrate this further, yesterday I was handed a very serious liver failure patient to care for. She was the same age as me. It was surmised that her liver failure came from a combination of an antidepressant and an antibiotic. Two benign little pills that caused this destruction. When liver failure is caused by drugs there is often a chance that it will reverse itself. This patient, however, developed sepsis, which (one) hindered her body’s ability to turn itself around and (two) ruined her eligibility for a transplant work-up.

So here I have a patient that is almost the opposite of how I was thinking in terms of liver failure. There is no “family meeting” and “withdrawing care” here. Does her liver still have a chance to reverse itself? Absolutely. And whatever organism caused her sepsis seemed to be winding down, which may soon put her in the running for a transplant.

But then two nice-sized clots in her right atrium were found. The first appeared to be a clot hanging from the tip of her dialysis catheter. The second could have been anything. Maybe even a big ball of fungus.

But doesn’t that just suck? I mean it sucks hard. There is obviously no black and white thinking in this case. It could go either way for this woman. I couldn’t help thinking that I was meant to care for her so that point could be illustrated to me. I have this passion for trying to find “the big picture.” On some level I’m trying to get at the gestalt of the thing, but sometimes I wonder if maybe it’s just the desire for a shortcut. There is so much data to process for the MICU patient. You worry about treating one problem at the expense of the others. And I’m just speaking from a nursing viewpoint. I would imagine that for the residents/interns this issue looms even larger. They have even more data to assimilate, and they are the ones actually writing the orders.

At any rate, I think I’ve finally developed the ability to care for a heart-breaking patient without actually having my heart broken. (I knew it would happen sooner or later.)

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On a (somewhat) lighter note: what do you do when someone other than a patient “codes” in the MICU? When a code is called in another part of the hospital, our docs are the ones that show up and run the code. Yesterday a patient’s mother “coded” twice. I put coded in quotation marks because it was more of a narcoleptic seizure. It first happened in the family waiting room. She was sitting in her wheelchair and just suddenly fell asleep. A hospital employee called a code. Twenty minutes later she turned out to be fine.

Then, at change of shift, she did it again, only this time she was in her son’s room. Someone noticed that she had fallen asleep and was unarousable. The resident started telling us that we would actually need to “call” a code because legally we couldn’t administer MICU code drugs to non-MICU patients. (???) So who was going to bring the code drugs to us, I wondered, the code fairy? At any rate, we really didn’t need any code drugs. A nurse slapped some zoll pads on her and a took a cuff pressure and an 02 sat. Her vital signs were unremarkable. Meanwhile the night shift nurses come walking onto the unit and immediately enter into “code” action mode but there was really nothing to do.

And the son (who was perfectly fine by the way, just watching TV, waiting to be transferred) says, “She’s fine. She’s been doing this for 48 years.”

I wonder how often this woman “codes” if she’s a narcoleptic? It really was quite an amusing visual. The son (who is the patient) is sitting up in bed with this wry smile, not looking the least bit sick, (I think he was in for one of those conditions where you appear fine but could crash any second, like hyponatremia). And the mom (who is not the patient) is slouched over on the wheelchair, hooked up to the zoll pads. The day nurses are looking bemused, the night nurses are looking bewildered, the resident’s waiting for the code fairy to show up.

Finally security came and agreed to wheel her down to the ER where she could be legally treated for her condition, whatever it was, and the son went back to watching TV.