most Interesting case/situation

I have an interesting patient to share with you all. Not sure if you'll necessarily LEARN anything from this, but it's definately an interesting case for sure.

We have a frequent flyer here at our hospital; a 23 year old woman who had rheumatic fever as a child and therefore suffered severe heart valve damage and had to have a couple of valve replacements. She is on coumadin therapy at home; she has some sort of gadget at home that she can actually monitor her OWN INR with... and, she keeps coming to the hospital with INR's through the roof; like, INR's of 25.0.

It took MANY visits to the hospital similar to this one before her heart doctors finally decided... hmmmm... this woman is PROBABLY doing this to herself. They finally figured out that she was deliberately taking too much Coumadin to make herself sick, and referred her to a psychiatrist.

Now, I haven't actually heard if she was ever diagnosed with Munchausen's Syndrome or not (that was their thinking). But, it definately would not surprise me if she was. She kinda had that "oh poor me, I'm SO sick, I've always been so sick, woe is me, look at me...." air to her.

Several years ago I had the cushy assignment we ICU nurses rarely ever get. Two stable patients who really didn't need a whole lot of care. Looked like it was going to be a great day. Then the critical care line rang...

An 11 year old girl had been involved in a high-speed head-on MVC the preceeding day. She had a serious seatbelt injury and had been taken to a regional hospital for stabilization. This regional hospital was (is) notorious for taking on cases they shouldn't even think about. Such was the story with this child. The seatbelt had ridden up on her abdomen and had actually been sitting just below her ribs when the van she was in collided head-on with another van at highway speed. Her skin was the only thing intact between the belt and her spine. She had numerous microscopic tears in her bowel, and the local surgeon thought he could repair it. So he did a resection and end-to-end anastamosis. She arrested on the table and was quickly resuscitated, then returned to their ICU, where her epinephrine tubing became pinched off briefly, causing a second arrest. When they finally called us, she was on epi at 0.2 mcg/kg/min, norepi at 0.5 mcg/kg/min and phenylephrine at 0.2mcg/kg/min just to maintain her systolic BP above 60. Her abdominal incision was open and the cavity packed. And she was on her way.

Now, having received patients from this hospital before who emerged from the elevator in full arrest with CPR in progress, I was more than a little nervous. I got all the drips ready and had them running into a 4x4 on the bed so that when she arrived, I could just hook her up and hope for the best. I was amazed when she arrived and was fairly stable. (The flight nurse who brought her was [is] the best there is.) She was sedated for transport but began to wake up soon after arrival.

After a few days we were starting to think that maybe this girl had a chance. She was still needing a significant amount of fluid in a day, and low-dose dopamine, but seemed to be rallying. Then her bowel perforated again. She made so many trips to the OR that I can't remember them all. They talked about a trach, but opted to leave her intubated. Each visit to the OR brought with it some new horror... continuous fecal spillage, colostomy, multiple sump drains, sepsis, fungemia, you name it and she got it. Her abdomen remained open and the surgeon came in daily to change the packing. She was getting several liters of fluid daily and still needed dopamine to maintain her SBP above 60. All the while she was coherent and cooperative.

Early in her fifth week with us, her coags started becoming really abnormal. She began bleeding from her nose, mouth, IV sites, rectum and lady parts. Her abdomen was looking very much like those pictures of cadavers in our A&P texts. On the evening of her 40th day in our unit, her TPN and dopamine were discontinued. Out of a desire to minimize discomfort for the child and her parents, she was kept intubated. I sat in a chair outside her room all night, watching her remote monitor and waiting for the inevitable. Unbelievably, every time her vitals came into the it-won't-be-long-now range, one of her parents would stimulate her in some way. They couldn't possibly have known about her vitals, the screen on the monitor in the room was blank and there were no alarms. Her mother would rub her arm or leg, her dad would tell her he loved her, or one of them would start to quietly weep. When I left at 7:30, she was still breathing.

The intensivist came in shortly after I left and at 8:10 she was extubated. She told her parents she loved them, that she wasn't afraid and that she was ready. As she died, she smiled.

I think about this young woman often. I wonder if I would have the same courage and grace.