Guinness book of world record has ranked bachelors of nursing as one of the toughest courses I the world, above medicine, engineering and architecture. This just explains that nurses are not average performers but high functioning scholars. Beyond being high functioning, nurses must have strong social, political, cultural and religious skills that equip them with skills to deal with all lows and highs of life.

Nursing pub is a place where nurses from all over the world share stories, experiences, and tips to the world about who we are. Besides stories, nurses at nursing pub offer health tips, answer public questions that may help make better health related decisions.

We are nurses and we stand together like one army from all over the world. We can be described in many ways but no one way can describe us well enough.

“I was there when you took your first breath. Cleaned you, fondled you and introduced you to the world. I prepared you to face the world. I gave you all vaccinations, taught your mother better ways to keep you safe. Day one in school, I was there as your school nurse. When you got sick, I was there in the emergency room, by your bed. Wiped you clean when you couldn’t control your bowels. I was there to feed you when you got too old to feed yourself. I tucked you in bed like I did when you were a baby. Even as you took your last breath, I was there, cried with your family, held hands and said a prayer.

I am not supernatural. I have feelings, blood and a life. I only eat after you have eaten. I pee only after cleaning you and make sure you are comfortable. I have been there for you throughout your life. Respect me”

I am a nurse

Recently I took care of a patient with testicular cancer and multiple metastasis to bones, lungs and the brain. This was a mid adulthood male who was admitted to the ICU with shortness of breath and pain all over the body related to pathological fractures.

The patient in his history talked about a lump he had on his testicles years ago and he described it as “itchy” lunp under the skin but didn’t hurt enough to seek medical attention. It went on for years and later he forgot about it as he got used to the mild itchy feeling in his scrotum.

On arrival to ER, the patient had been having shortness of breath with blood tinged sputum and sudden weight loss. He also complained on bones pain all over the body and on x-ray, he was found to have pathological fractures of long bones of the upper and lower legs bilaterally. He also got a chest x-ray that showed multiple masses in his lungs consistent with lung cancer.

Further, the patient was sent for CT-Scan of the whole body and was found to have brain masses sitting on the 4^th ventricle and brain stem areas. The outcome is almost certain that it was just a matter of time before bidding goodbye to this world.

Any physician at such a time when a patient has stage 4 cancer would explain things to the family and facilitate end life tough decisions. This was done and with Hispanic community, letting go of a loved one no matter how sick they are is never an option. Hispanics are known to keep their patients even when there is no possibility of survival.

Chaplain was contacted and after the family insisted that everything possible should be done to save the life of their loved one, the doctors in ER sent the patient to ICU and I was the one to take care of this patient.

Immediately on arrival, serial labs were ordered and drawn. The physicians in ICU without wasting time inserted a central line anticipating the need of good intravenous access for fluid resuscitation.

The patient shortness of breath was getting worse by the minute and the doctors decided to draw an arterial blood gas to check oxygenation status of the patient. In 15 minutes the results were called from the lab as panic with CO2 level of 78. The normal CO2 level in arterial blood gas is 35-45. The oxygen level was only 42 (normal is 78-95). This warranted immediate intubation to secure the airway and optimize oxygenation.

Anesthesia team was paged and within a matter of minutes, they arrived in the ICU and intubated the patient. Everything was explained to the family that he might never be able to breathe on his own for the rest of his life. The family insisted that they wanted everything done.

The following day, the oncology experts evaluated the patient and was started with chemotherapy. Radiation therapy was not an immediate option as cancer had spread to many parts of the body.

The first round of chemotherapy was done with every expectation explained clearly to the family. The patient was first given 4 units of blood as he had very low hemoglobin count. He also received several units of platelets that he needed the most.

24 hours after the initial chemotherapy dose, the patient was literally fighting for his life on the ventilator. His heart rate was in 160’s and poor perfusion was evident. Doctors were concerned because of the fact that the bone marrow was destroyed so bad by cancer that the patient was barely making any new blood cells. This meant that the patient had to be transfused many times with multiple blood products.

The struggle fighting for life went on and on and eventually, he coded after being in ICU for about 2 weeks. His bones were so fragile and brittle that CPR the sternum and most ribs, making it a bloody experience.

He died days later after his initial arrest, leaving behind a wife and three beautiful girls. The youngest was 6 years old and the oldest was 10 years old.

Everyone in the unit was feeling the pain just imagining the family and the loss they have incurred. No words could have been good enough for the young girls who came to bedside to view the body of their beloved dad. No tears were painful enough than those shed by the wife, a homemaker who never had a job and could barely speak a word in English. It is a life ahead full of broken dreams for the family. It was an experience painful enough even for doctors and nurses who took care of the patient until their final breath.

Moral of this story

1. Testicular exams are very necessary and every man should do it every month.
2. Never ignore anything that feels or appear abnormal to you. See a doctor immediately for evaluation.
3. Testicular cancer is curable if identified early. Lance Armstrong survived it because it was caught early before metastasis.
4. Testicular cancer can metastasize fast especially to the spine, lungs and the brain. The earlier it is diagnosed, the better the outcome.
5. Multiple organ metastasis called stage 4 cancer and has poor prognosis. Chances of surviving stage 4 cancer are very low, sometimes none.
6. When cancer is a true end stage, hospice care could be a better option that aggressive treatment which the already cancer weakened body cannot tolerate.
7. There is no age too young for cancer. Testicular cancer is commonest between 14 and 40 years. This is such a young age that a lot of people may not think they are in danger.
8. Testicular cancer is one of the most curable cancers known but it has to be identified early enough to increase chances of survival.
9. Any pain, swelling, lump, lack of sexual interest, blood in the semen, lower abdominal dull ache should be reported immediately to your physician.
10. Annual physical exams are vital in detection of testicular cancer.

Gastro-Esophageal Reflux Disease  (GERD) Case

Gastro-Esophageal Reflux

I know it has been a while since I last posted an ICU case but today I have an exciting one about GERD. I am sure most of you already know what Gastro Esophageal Reflux Disease is or at least have heard the word FERD. Gastro-Esophageal Reflux Disease is a very common disease that affects people of all ages and commonly known as heart burn. When you talk about heartburn though, you should be aware that it is not all heartburns can be called GERD.

As usual, I never give any personal identifying information to keep privacy in observance of HIPPA laws. This case about Gastro-Esophageal Reflux Disease is about a young male in 40’s who was admitted in ICU in critical condition.

The patient went to seek medical help after he couldn’t swallow anything including his own saliva due to pain. On arrival to ER, he had very low hematocrit and appeared malnourished.

His heart rate was in130’s and 140’s and his blood pressure was very low with systolic blood pressure of 70’s and 80’s. These are critical findings on admission that made the patient to be automatically admitted to ICU. Immediately he arrived in the ICU, the GI-Team came and did an endoscopy on him only to find that his esophagus had eroded so much to a point of having perforations. There was no way to repair such a damaged tissue other than to remove it.

In Gastro-Esophageal Reflux Disease, the acid produced in the stomach regurgitates through the esophagus and can be felt as a burning sensation with belching. Sometimes it may be happening when a patient is lying down especially at night sleeping and so may not be noticed immediately until some significant changes have occurred.

This patient had to be taken to operating room for a long urgent surgery to repair his torn esophagus. Can you imagine acid so potent that it can erode your esophagus to a point of getting perforations? In surgery, the surgeons took out his esophagus all the way down to the stomach. Then, they cut a part of his small intestine called Jejunum and improvised it to become his new esophagus. This was a long procedure that took hours by a team of 3 surgeons.

So I took care of this patient for 2 days and it has been in a while since I saw someone in so much pain that even on dilaudid epidural pump, the guy was still in pain.

You will notice that I am changing the style of my nursing stories. I am changing it such that anyone reading this blog post can benefit from it whether you are a nurse like me or you are a consumer, someone who might be a looking for information about the topic am blogging about.

So what causes Gastro-Esophageal Reflux Disease?

GERD is mostly caused by foods we eat and lifestyle and we have a lot in our hands that we can control to avoid GERD.

Certain foods and lifestyle are considered to promote gastroesophageal reflux:

1.      Coffee alcohol, and excessive amounts of Vitamin C supplements stimulate gastric acid secretion. Be careful the way you take your vitamins. Taking these before bedtime especially can cause evening reflux.

2.      Antacids based on calcium carbonate (but not aluminum hydroxide) were found to actually increase the acidity of the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may still be positive.

3.      Foods high in fats and smoking reduce lower esophageal sphincter competence, so avoiding these tends to help. Fat also delays stomach emptying.

4.      Eating within 2-3 hours before bedtime.

5.      Large meals. Having more but smaller meals reduces GERD risk, as it means there is less food in the stomach at any one time.

6.      Carbonated soft drinks with or without sugar.

7.      Chocolate and peppermint.

8.      Acidic foods, such as oranges and tomatoes.

9.      Cruciferous vegetables: onions, cabbage, cauliflower, broccoli, spinach, brussels sprouts.

10.  Milk and milk-based products containing calcium and fat, within 2 hours of bedtime. Now this sounds tricky as you may have heard that milk actually help curb GERD. NO, Milk only makes you feel relieved as you swallow it down soothing your esophagus. Milk also causes a lot of thick mucous secretion (take warm glass of milk and try to spit. You will see how much thick mucous you gotJ)

Now that you know what may cause GERD, what are you going to do about it? Do you think you might be doing something that might put you at a risk of having GERD? Or do you actually have GERD but not aware of it?

¨       If you sometimes feel like there is something in your throat that you can’t swallow, you may be having Gastro-Esophageal Reflux Disease.

¨       If you sometimes get horse in your voice especially in the mornings, you may have Gastro-Esophageal Reflux Disease

¨       If your baby/children are having tooth decay that is linear or has a pattern, they may be having Gastro-Esophageal Reflux Disease.

¨       If you sometimes feel hot sour tasting regurgitation in your mouth, you may be having Gastro-Esophageal Reflux Disease.

¨       You need to see your doctor.

The patient walked to ER with his tongue swollen so much that he could not talk. Everyone was surprised to see how bad it was and immediately, ER nurses attended him. Within no time, the patient started having problems breathing due to blocked airway.

As you know, if your tongue is so swollen that it is protruding out and bit by the teeth even with mouth open, chances are that the intubation would be very difficult or impossible.

The ER doctors tried to do nasal intubation but they were unsuccessful. The patient kept having hard time breathing and this time, they had to do an emergency cricotomy. This was the only way to safe his life from saffocation.

When an allergic reaction is this severe, swelling is the most predominant sign that you see. The attempt for bedside tracheostomy was dangerous due to swollen airway and this meant that the patient had to be rushed to operating room to have an emergency cricotomy done under anesthesia.

In OR, they immediately knocked the patient out with paralytic drugs called vecuronium and succinylcholine, followed by fentanyl for pain and as anesthesia adjunct. Instead of the planned cricotomy, they did a tracheostomy and was successfully done. Finally, the patient got a patent airway.

The patient was transferred to ICU where he was stabilized and treated with high doses of steroids and anti-histamine in an attempt to lower his swelling.

Unfortunately his tongue remained very swollen and having hard time breathing on his own. Chest x-ray showed fluid accumulation in the lungs. Normally, this happen when there is an anaphylactic reaction. The blood vessels become permeable and fluids leaks to open cavities (third space) like lungs, in this case.

Angioedema is common in African Americans taking ace-inhibitors for blood pressure issues. Over 94% of all cases of angioedema are caused by drugs such as ace inhibitors (e.g. lisinopril).

To cut the long story short, I found a picture online that looks close to how this patient was. Please know your allergies and keep an allergy band on all the time. It might help save your life.

See eMedicine Health overview about Angioedema