Tuesday, March 24, 2009

Systems Note

Day + 11 Health Score 72

I am a little tired today as they have stopped the steroids and my body is using all of its energy to rebuild a new bone marrow and heal all of the other damaged tissues. But, despite that I feel wonderful. I had a visit from my Home Teacher from church who drove all the way from Lincoln and while he was here found Coldplay tickets for their concert in Marysville for July 14. What a treat to look forward to.

When doctors write a simple note on an uncomplicated patient, they use the SOAP note format.
S: Subjective
O: Objective
A: Assessment
P: Plan

A patient in an ICU setting has more that one system that may be failing, so they do a systems note; assessing each system individually. these generally include: CNS/mental status, cardiovascular, pulmonary, gastrointestinal (GI and nutrition) Genitourinary (kidney function) Hepatic, Infection, Immunologic and blood.

If more three or more systems fail simultaneously, it may be difficult for the patient to recover.
Last week my systems review was as follows: Infection: on Thursday I went into septic shock with a blood pressure of 60/35. My fever was 101.6 and I stopped making urine. I was resuscitated with 5 liters of fluids and 1 liter of blood. This only brought my blood pressure to 80/60 and still no urine output. (30 cc/hr). Finally, I was put on 5 mcg of Dopamine which raised my pressure to 95/60. Pulmonary: The next day a chest CT revealed bilateral basilar pneumonias. I was started on aggressive antibiotics and my fever decreased and breathing improved within 12 hours. Vascular: The infection caused my peripheral vessels to collapse and become leaky allowing all of the intravenous fluid to leak out and cause massive edema. Kidneys: The combination of dehydration and toxic drug effects caused my kidneys to fail and my creatinine went from a normal of 1.1 to 2.6 in 5 days (it is now down to 1.6) This made it difficult to get rid of the extra fluid. Mental status: I only had some mild delirium which last two days and only when I nodded off and would gesture and speak audibly to people in my dream. Gastrointestinal: The combined toxic effect of melphalan and edema on my gut made for a complete inability to eat. This, in addition to painful mouth sores meant no nutrition for 6 days. Fortunately the mouth sores last only two days and ended before the sepsis began. Imunologic: On vacation for the duration. I had zero white cells to help fight off the infection. That was the whole point of the transplant, and they weren't back yet. nor were my platelets to prevent bleeding, but transfusions of platelets and blood saved me in this category. Two systems were left. Hepatic: my liver remained healthy managing to metabolize all of the new drugs in my system. But my heart was the star. Cardiac; Early on I worried that all of this stress would put my heart into rejection; but an echocardiogram revealed that my heart was working above normal physiologic levels. It alone was keeping me going. It was perfusing my kidneys so that they could heal. It was maintaining my blood pressure even when they turned off the dopamine, but most critically, it was keeping my lungs free of excess fluid allowing me to breath. And possibly preventing the most dreaded of complication Adult respiratory distress syndrome or ARDS. Which by itself can have a 50% mortality rate.
As my cardiologist told me, "Your heart is doing a great job". I had to think, "My heart?" It is actually my 'shared' heart. And this is now the second time that it has saved my life.



Anonymous said...

As my cardiologist told me, "Your heart is doing a great job". I had to think, "My heart?" It is actually my 'shared' heart. And this is now the second time that it has saved my life.

THAT HAS MY EYES all filled up hehe
no one can fully understand that feeling unless you are the one with someone else heart. Wow!!!!!!!!!!!
that is just so awesome!!!


So glad to hear your getting stronger everyday!

Unknown said...

Thank God! you have turned the corner and the SCT has taken. I had not read your blog for a few days (since Sat.) and so I missed the further "scary" part but got to read the wonderful news too! all at the same time. You certainly are tenacious! I sense a celebration will be coming soon. Thanks for the photo too. You look "marvelous darling!"

Anonymous said...

I'm so touched by your scientific explanation of all your systems, including your blessed heart.
I'm tearing up thinking about how hard it has worked to support your depth of spirit and the strength given by all the loving prayers.
I send my love in heart-felt gratitude.