AIDS Meets My Reality

I had my first AIDS patient on Thursday during my clinical round. I don't really know what I expected before meeting my patient, but I think that what I experienced really helped blow all expectations out of the water.

When thinking of AIDS, I think of 1) homosexuals, 2) someone who seems really bitter, and 3) someone who is very sick. At least externally, my patient did not fit these stereotypes. He may have been gay, and that would be fine, but I think the fact that he didn't line up with this stereotype was a very big help to me for my first experience with this disease. I'm not the most biased person in the world, but I can still recognize that I have my fair share of bias towards certain lifestyles, especially those that I disagree with. (In case you're wondering, yes, I'm a Christian, and no, I don't think that just because someone is gay means they're going to hell. Homosexuality as a practice, according to the Bible, God's word, is sinful. It may not seem fair and it's far too easy for me, a heterosexual, to make such a claim when I have nothing to lose, but it's not my word, it's God's. But at the same time, homosexuality is not the primary defining characteristic of a person. I recognize that it is only one small aspect, just as me being white or American is a small part of my own personality. That said...) I found it a joy to take care of this man. He was very kind, polite and he made good conversation. I felt bad that I had to ask him so many questions and continually interrupt him to give him meds, take vitals and give instruction regarding healthcare practice. This patient put a new face on AIDS for me.

I think I have only begun to understand how horrible this disease is. His meds, I believe, have given him chemical pancreatitis. This is life-threatening and, I suspect, can be very painful. Because of this, he stopped taking his medications 6 months ago and now has a CD4 count of 1. That's bad, just in case you weren't sure. He had a couple different infections going at the same time too. I couldn't help but have compassion on the man. According to my instructor, he's looking a lot better since he arrived at the hospital some weeks prior. But I know that he doesn't want to be discharged. There's too much responsibility to carry by yourself with this disease. Too many do's and do not's. Too many pills to swallow. People with this disease need our help. They need our compassion, not our admonishment (assuming they got the HIV infection through risky sexual practices). Though the drugs may help them live much longer than 15 years ago, there still isn't a cure (and I suspect some people, many who call themselves "Christian," hope there never will be one since some feel this is "God's curse to fags"). I for one hope a cure will be found. I hope that I can find some way to be more caring towards the AIDS community both here in the states and world-wide.

With Great Blood Type Comes Great Responisibility

Yup. I donated blood today. I remember being too scared to donate when I was a senior in high school. I really hated needles then. But on Urban Project, an inner-city mission in San Diego, I decided to be brave. And it wasn't that bad. So I think today was probably the 6th or 7th time I've donated. Working at a hospital I see how great the need is for blood donation. I've probably had 20 patients get a blood transfusion since I started working as a CNA and having clinical rounds. And supposedly the blood levels are very low currently. That's really bad. They're the lowest for O+ and O-. And I just happen to be O+. That means that when I give blood I'm very generous because my blood can be received by about half the world: anyone who has the Rh antigen on their blood cells. But I'm also very sacrificial, because I can only receive blood from O+ and O- donors. I would have a hemolytic reaction (kill the new blood cells) to A, B or AB and that might send me into anaphylactic shock! Just a little 411 on blood chemistry for ya'll.

Well, today I did a new procedure. I gave 2 units of packed red blood cells. This is a little more extreme than your average blood donation, which is whole blood (serum and RBCs). In this procedure, they take out your blood and then reinfuse most of your serum; this contains H2O, platelets (things that help you clot if you bleed), and white blood cells (WBCs, these fight against of variety of infections). The procdure takes about 3 times as long as a normal donation, but worse than that, when they reinfuse you with your serum, it's really cold. My arm was still cold 5-10 minutes after the infusion stopped. I was shiverring all over and needed a blanket. I felt like such a wimp. But my wife assures me that I'm brave for even going in the building. Thanks honey. :)

TV totally adds 10 pounds...

Before I talk about today's experience, here's how I did on the test. 85%. 34/40. Not what I was hoping for, but all I need to do is pass, right? Oh well...

Today I went to Endoscopy. That's where they stick a camera down your mouth or up your..... Anyway, it was pretty cool, but not something I want to do as a nurse. It's the same thing really. You help the doctor out where necessary, teach the patient and help them get dressed once the Versed (sedative) wears off. Eh...

I'll spare you the details, but I will say that TV does actually add 10 lbs to your colon. It was pretty cool to get to see the doctor guide the tube into the bowels. It looked really easy until a doctor who was learning gave it a try. It definitely takes some finess. Oh yeah, this isn't so much gross as just kind of funny. On the first endoscopy I saw, once the tube passed the gastroesophageal sphincter, I thought I was looking at the brain. The stomach is really wrinkly inside, but very pink if you haven't eaten for about 9 hours. Most the bowels I saw were very clean. ;) Some weren't though :(

Oh, and I've decided to get TED hose. I'm getting varicose veins and I figure I don't want to risk getting a venous stasis ulcer, really ugly legs and more pain (it actually hurts even before they get bad). Sigh... Thanks Dad!!!! (these things are hereditary).

Since I'm posting pictures, I'll explain why varicose veins occur. First of all, it's a genetic defect in the veins. Leg veins have valves, much like the Aortic and Pulmonic valves in the heart: they all blood to flow only in one direction. In dysfunctional venous valves, they don't keep blood from back flowing. That can cause blood to stay in the interstitial space. When pressure gets too high in the legs it can keep nutrients from circulating to the skin. This can lead to skin breakdown and lack of upkeep in the cells. That's when venous stasis ulcers can occur. The way to both treat and prevent this from happening is by applying pressure, thus my decision to get TED hose. If I can save myself some pain and my family some money, then I think the inconvenience of wearing them might be worth it. We'll see...

Anticipation

Arrrgggghhh!!! I took an exam online 6 days ago now and my score still isn't posted. This is giving me so much anxiety. The test covered nursing care for patients with fluid/electrolyte/pH imbalances, respiratory problems, and cardiac problems/dysrhythmias. It was only 40 questions. I know I got at least a C, but I'm not quite sure beyond that... I don't know why I'm letting this get to me, but eh...

On another note, I do sincerely apologize for being somewhat grotesque with my last two postings. I do thing both because I want you to continue to read my blog and also because I don't like making people feel unwelcome/uncomfortable. I can't promise I won't leave a few details out in the future, but I'll keep it a minimum. Besides, I have find some way to deal with the psychological trauma I experience when I see a human body in a near death state.

And on another note. God is good. He has given me hunger for knowledge and I have studied at least 3 hours today with 2 more hours til Shannon comes home. Yah!

The Foley

It's eluded me for over a year now. But finally, today of all days, minutes before my clinical round was to come to its end, I inserted my first foley catheter. Yes! This was the moment I was waiting for. This was the moment that I will look back on and say, "That's when I made it. That was my homecoming. That... was the day I became a nurse." Ok, maybe not. Actually, that day will come when I prove a doctor wrong. hehe

So I inserted my foley. It wasn't so bad and not too difficult. But it wasn't fun for my patient. He was about 84 and already in some pain, so I just made a bad day worse coming from his perspective. Anyway, the procedure is sterile, meaning that you have to open everything in a certain way, put on sterile gloves at a specific time, and make sure you don't touch anything that is non-sterile until you're ready to do so (like the sexual organ of your patient). You clean the area with idodine. Make sure your foley catheter is working properly (a balloon inflates with water at the tip once it's inserted; this prevents it from dislodging or moving back and forth which can lead to infection).

Then you lubricate your foley. Um... actually... I lubricated the inside of his urethral meatus. Yeah. I actually injected his member with lubricant. I was told to do this by my instructor. I thought she was crazy, it makes sense. It probably was a lot less irritating when I shoved inside past the prostate, which was probably a little larger than normal due to his age. Not much urine came out though; he's in end-stage renal failure.

Well, that was today's highlight. I also gave my first nicotine patch today and gave two injections (insulin and lovenox, an anticoagulant). Life is changing so quickly. Last year I was scared to be in the hospital. Now I feel like it's my home away from home. God has really done a big work in me to get me this far. But I digress. I'm gonna have some pizza now and do some work so I have the weekend off. Shan and I are driving to El Centro to hang out with my parents on Saturday. Yah!

The OR

Open Heart Surgery. Need I say more?

Well, probably, because you really have no idea what is involved until you hear all the procedures involved.

The patient I saw was getting an aortic valve replacement (bovine aortic valve). First you get the patient ready, give them an IV and then knock her out. Next, insert a foley catheter (muscle reflexes are down to minimum, you wouldn't want your patient waking up in a pool of urine.)

Then insert a SWAN catheter. This is a form of a central line catheter, but after entering through the sub-clavian vein a blood-pressure sensor is sent through it into the pulmonary arteries (that inside the lungs) to assess the BP in the right ventricle and pulmonary arteries. It also has two lines that can be used to send drugs straight into the heart.

Next, completely cover the patient with iodine and a celephan-like substance to ensure asepsis. Then you're ready to start cutting! Cut through the skin directly over the mid-sternal line over the heart. Then pull out your Mikita buzz-saw and go right through the sternum (I'm not kidding). Then start cauterizing the lining protecting the heart, the pericardium. Then, there she is, the most amazing muscle of the human body, the heart. You might get to see the lungs also.

Now comes the tricky part. You have to cannulate the Aorta. This involves sticking a plastic tube inside it just after it leaves the heart. Then you stop the heart by shooting it up with large amounts of potassium, which you hopefully can flush out when all is said and done. Then you cannulate the Vena Cava and turn on your blood fusion machine: In the Aorta, out the Vena Cava, through the machine and back in the Aorta. It's pretty cool.

Finally, you can cut the bad-boy open and cut out the stenotic (tight) aortic valve. Then it's a long process of sewing the cow aortic valve in. Then you stitch it all back up, de-cannulate, and shock the heart back into motion. Last of all, you sew the patient up, using stainless steel to bring the sternum back together, making sure to turn the stitches down so they don't go through the skin. Also, you might want to cauterize any bleeding vessels as that might present a problem when the patient is trying to heal. Then send your patient to the Surgical ICU. You're done.

PS - I hope you didn't mind the smell of burning flesh.

Coffee and a Good Book

I went to Starbuck's yesterday near Shannon's work to study. It's amazing how concentrated on study I was. I usually am extremely distracted at home. Maybe I'll make this a normal study habit... It may be a bit costly though: $3.50 for my mocha, but you know, it kind of tasted like dirt and wasn't very enjoyable since I only had my books to share it with. But I didn't let them have any (Thank God! I hate when my books try to drink my beverages).

I worked on a kardex and plan of care for a patient I had last week. Although it is a lot of work, I found myself enjoying it. I didn't feel rushed, which is a nice feeling. And I enjoyed learning about lab values and attaining more of a nursing perspective when developing a plan of care for my patient.

the PICU

PICU stands for pediatric intensive care unit. It was pretty intense. I saw 2 month old girl that had been physically abused. A 5-year old boy was there for suffering a brain aneurysm; they actually went into his brain to drain cerebral spinal fluid from the ventricles (that's like dead center of the brain) in order to relieve intracranial pressure.

The patient I had is comatose and they really aren't sure why. He had some seizures, so he might have suffered some brain trauma, but they don't know why he had the seizures to begin with. They think it might be Acute Disseminated Encephalomyelenitis (ADEM), but they really aren't sure. Some doctors think it could be a "metabolic problem" which really just means they've eliminated all other possibilities and are ruling out a mitochondrial disorder. The ADEM is supported by a CT scan (computerized tomography), which shows what think is a distruction of the myelin sheath in the brain. Myelin is a coating that many neurons in the brain possess which increases the nerve impulse speed.

Currently, my patient doesn't have deep tendon reflexes. Like when you swipe the bottom of his feet (Babynski reflex), he doesn't respond to that. His pupils are round and reactive to light, but they don't react very quickly. I felt so bad for the patient's family too. I'd hate to be in their situation. But there was one patient who was a happy case and I didn't realize it. She was a 2 month old who was born with a congenital defect in her heart. She had a perforated septum between her ventricles. This actually not rare and is easily remedied. She is recovering nicely, will probably be off the the ventilator tomorrow and will be in mommy's arms in two days. If there are cases like this to look forward to, I just might be able to hang in there with the kids. If not, I don't know what I'll do, cuz they break my heart when I see them in those beds with all those tubes coming out of them.