by Christopher Graham
One thing I didn’t realize about the hospital was that you’d get a different nurse most nights. It seems obvious in retrospect – nurses have odd days off and work weird hours just like we do. I had just never thought about it, really. But that meant that I got to meet different types of people and see different nursing styles. It was really interesting, actually.
Some of the nurses would look the other way when I snuck a few extra sips of water from the pitcher, or they’d fill it up with ice for me to ostensibly chew on, but they’d let me sip on the water that melted at the bottom. These nurses, I decided, were the nice ones. And I liked them. Other nurses were real sticklers about sneaking extra sips. I’d get yelled at if I got caught. So mostly I practiced not getting caught. Even though I knew it was in my best interest to follow the fluid restrictions, I was so desperate for water that I couldn’t stop myself from trying to get every drop I could. Those nurses though, I knew, understood the rationale for the fluid restrictions and the importance of following them. And so, to me, they were the smart ones. I decided that I liked them too, though perhaps just a little bit less than the nice nurses. But in reality, all of my ICU nurses were both smart and nice – they were total rockstars and I liked all of them. And please let me say, thank you for taking such good care of me, my esteemed colleagues! I always felt I was in completely able and competent hands.
As I said above, though, all of this stuff was part of a larger problem – my severe kidney injury. My lab numbers kept getting worse and worse each day, until, six days after the surgery, they finally decided I needed dialysis. If you’re not familiar with dialysis, it’s basically a medical treatment designed to reproduce the function of your kidneys. Practically, how that works, is that we hook you up to a big machine that filters out all the bad stuff from your blood that your kidneys would normally remove. It also helps keep your electrolyte levels, things like potassium and sodium, in the right range. And it takes a machine the size of a pretty fat human being to do the job of your kidneys, which together weigh not quite one pound. The human body is truly a magnificent machine (at least when it’s working right).
Your kidneys, on any given heartbeat, get about 20-25% of the entire blood volume that your heart pumped. So your kidneys are constantly filtering the blood, and not a small amount of it, either. To reproduce the function of the kidneys, you need a very large bore tube into one of the big, central blood vessels in your neck or leg to be able to get enough volume of blood out of your body, through the machine, and back into your body.
One of the things we do in interventional radiology is help place such lines for long term IV access. For someone like me, someone who needs dialysis for some finite but as-yet unknown period of time, we place something called a “tunneled line.” The main part of the IV, the part that is actually inside the vein, goes into your neck vein. Then, instead of coming through the skin right at the same site, the tubing is tunneled underneath the skin for a few inches, and then the tube pops out through the skin on the chest. We tunnel them like that because it greatly reduces the risk of getting a bloodstream infection. The part that hangs out has connectors so they can hook you up to whatever. I was headed down to IR to get my tunneled line.
I’ve placed those lines in patients myself. I had been the physician, the last time I was in that particular procedure room. This time, I was playing a different role. And it felt really weird. The attending who did my case came in to talk to me about the procedure. I knew him well, and we had worked together and taken call together in the past. We both looked at each other for a second and then just laughed. He handed me the form and I signed it. I knew exactly what it said. I knew all the risks and benefits. I was usually the guy doing the handing of the form and the explaining of the case.
They gave me the medication for conscious sedation and I promptly fell asleep. It really does feel like you’re “out” for most of the case with that stuff, even though the word “conscious” is still in there. You’re basically asleep or so tired that you just want to close your eyes, and you don’t really care what’s happening to you. But we like conscious sedation when we can get away with it in medicine, because you don’t have to hook the patient up to the breathing machine. They continue to protect their airway and breathe on their own. With general anesthesia, you’re actually given a paralytic agent in addition to the thing that knocks you unconscious, so we have to breathe for you or you’re toast.
What I think they may not have taken into consideration when they gave me the meds was the fact that my renal function was, as we say, “in the shitter.” That’s another one of those official medical phrases. The two drugs we use most often for conscious sedation are fentanyl and midazolam (trade name Versed). Fentanyl is a painkiller similar to morphine, and midazolam is an anti-anxiety medication like Xanax or Ativan. When you get them both together, you feel pretty freaking good. Both of them are primarily excreted through the kidneys. So as you might imagine, if your kidneys aren’t working, the drug isn’t being excreted as quickly. They gave me a pretty decent dose of the stuff, too. I had been undergoing so many procedures with these medications, lately, that I was building up a tolerance. But this time, the dose didn’t really go anywhere. It couldn’t get excreted, so it just circulated, and it hit me pretty hard. I guess I was saying some pretty weird things to the IR folks, but I don’t really remember it. That’s just what I’ve been told after the fact.
Continue reading in the next installment by Christopher Graham here: Chapter 3 | Part 5: The Dangerous Reality of Opiate Medications
Read the previous installment by Christopher Graham here: Chapter 3 | Part 3: The Single Worst Physical Experience