2: Medical Problems and Treatments

in a Hospital or an Intensive Care Unit (ICU)


Lung Problems

Brain and Thinking Problems

Very Low Blood Pressure with or without Severe Infection

Heart Problems

Kidney Problems

"GI" Problems: Bowel, Liver, and Stomach

Blood Clots

High Blood Sugar


One of the most frightening things about the Hospital ICU is trying to understand what the doctors and nurses are saying. Often, the healthcare team uses too many big words that are hard to understand or remember. This chapter of the book is meant to help you by talking about medical problems that occur often in the Hospital or ICU.


Lung Problems


Pneumonia


Pneumonia is an infection of the lung. People can catch pneumonia for a lot of different reasons. Pneumonias also happen in the because people in the hospital are usually sick from other diseases or problems. All bugs find it easier to attack sick people. A lot of different bacteria (bugs) and viruses (like the flu) can cause pneumonia. Even though a pneumonia or flu shot reduces the chance for getting some kinds of pneumonia, people can get a pneumonia even if they have had a pneumonia or flu shot.


Patients with pneumonia often need to have antibiotics to help fight the infection that is making them sick. Knowing what bug is causing the pneumonia makes it easier for doctors to pick the right antibiotic to help the patient. Sometimes the doctors will sample the lungs to try to find the bug that is causing the pneumonia. This procedure involves putting some fluid down into the lungs and then sucking it back up and sending it to the laboratory


When pneumonia is very severe, pus fills the inside of the lungs. Doctors can see the pus as a change on a patient’s xray. When there is a lot of pus, it is hard for oxygen to get into the body. Many patients with pneumonia need to be on an oxygen mask. Others need oxygen through a tube that goes into the nose or through a tube that goes into the mouth and into the lungs (this is called a breathing tube).


Most patients recover from pneumonia and eventually have completely normal lungs. But healing can take a long time and some patients, particularly those that had lung problems before getting pneumonia, may take a very long time to come off the breathing maching Sometimes the bugs that cause pneumonia can get into the bloodstream and cause a blood infection, making the patient very sick (see section on sepsis). Even when everything is done right for a patient, a patient can die if their body doesn’t heal from the pneumonia.


Breathing Machines or Ventilators and Hospital Acquired Pneumonia


When a patient needs a tube going into his/her lungs in order to get enough oxygen, the patient also needs to be on a breathing machine, which is also called a ventilator. There are several kinds of breathing machines. A breathing machine breathes for patients and helps the lungs to get enough oxygen. The breathing machine does not cure the lungs of pneumonia, but does help the patient until the patient's body is able to heal.


Doctors can adjust a breathing machine to do a lot of the work of breathing or very little...it all depends on what a patient needs. Sometimes a patient has to be given medicines to relax or weaken muscles so that the breathing machine can do its work better. People who have been on a breathing machine for a long time often need time for their muscles to become strong enough to do all the breathing again.


Patients can get pneumonia while being on the ventilator because the breathing tube that goes into their lungs can act like a highway for bugs----bugs can crawl down the tube and get into the lungs. The hospital and ICU staff work hard to try to keep this kind of pneumonia from developing, but for every day on the ventilator, there is a 3% (or 3 in 100) chance that a patient may catch this type of pneumonia. Because it is so common, the doctors and nurses also look for this kind of pneumonia and are quick to treat it.


ARDS—adult respiratory distress syndrome


ARDS, which is short for adult respiratory distress syndrome, is a special kind of scarring that damages the lungs. Many different things can cause the scarring, just like many different things can cut you. Things that may cause the scarring include infections (pneumonia or blood stream infections), bruising on the lungs from a car accident, blood transfusions, even being on the ventilator itself.


No matter what first “cut” the lungs, the scarring that develops can be a big problem. In order to get air/oxygen into the body, the air/oxygen must cross a very thin layer of tissue. When a scar forms on top of this tissue, it becomes harder and harder for the air/oxygen to get into the body. The lungs, which are normally very soft, become very hard, thick, and heavy.


In order to get oxygen into the body, patients with ARDS almost always have to be a breathing machine, also called a ventilator. The breathing machine does not fix the scarring in the lungs, it just gives time for the body to clean up the scarring, just like the scar on your hand will eventually fall off.


There is no cure or treatment for ARDS. If the scarring of the lungs becomes very serious, the breathing machine will not be able to help. One in three patients who get scarring of the lungs, or ARDS, will die from this disease. The patients who survive ARDS, take a long time to get better. Even after being out of the hospital or ICU for a whole year, patients who had scarring of the lungs may have some problems breathing and may feel weak.




Lung Bruises (Pulmonary Contusion)


People who are in severe car accidents or who have a bad chest injury may develop bruising of the lungs. This is called pulmonary contusion.


Some lung damage cannot be seen right away. When you bump your leg on the corner of a table, it often hurts right away, but the bruise does not show up for a couple of days. After you start to see the bruise, it starts to look uglier and change colors, even though it isn’t hurting anymore. Bruising of the lungs is very similar. Although the car accident or injury is what actually hurts the lung, we cannot “see” the bruising on an xray for three or four days. After the bruising shows up, it can get worse and worse on the xrays before it gets better.


Bruising of the lungs makes it hard for oxygen to get into the body through the lungs. Patients with bad pulmonary contusion, or bruising of the lungs, often require a breathing machine, which is also called a ventilator.


Most people with lung bruising get better, but they usually need at least a week on the breathing machine. If it is taking a long time for the lungs to get better, doctors may need to put the breathing tube in the neck, instead of the mouth.


Collapsed Lung or Pneumothorax


When a patient develops a small hole in the lung, the lung can collapse. This is called a pneumothorax. There are a lot of ways that a patient can develop a hole in the lung. Occasionally it just happens. More often a hole in the lung follows a bad car accident or after being hit very hard on the chest. Or a pneumothorax happens because the patient has a bad disease of the lungs, like emphysema/COPD/tobacco lung. Some infections can cause a collapsed lung. Occasionally a hole in the lung results from a procedure---for example, when doctors put large tube (IV) into a vein at the neck or by the collarbone, the needle used to put in the IV can hit the lung and cause a small hole.


Regardless of what causes the hole in the lung, the hole allows air to leak out of the lung. Because the air is inside the body, it has no where to go. The air takes up space that the lung usually needs and the lung collapse.


To get the lung to re-inflate, doctors need to put a tube through the ribs into the chest. This is called a chest tube. A chest tube allows the air leaking from the lung to escape so that the lung has room. A chest tube does not fix the hole in the lung---the body needs to fix this hole. It can take more than two weeks for the hole in the lung to seal. The chest tube cannot come out until the hole is sealed.


Patients on the ventilator or breathing machine who have a chest tube often need to have the chest tube for as long as they are on the breathing machine. This is because the pressure of the air moving in and out with the breathing machine can re-open the hole in the lungs.


Having a chest tube can be very painful to patients who are awake. Patients with chest tubes often do not want to take deep breaths because it hurts too much. It is important that patients get enough pain medicine to be comfortable and to take deep breaths because not taking deep breaths can cause the lungs to collapse or to develop pneumonia.


Fluid Around the Lung or Pleural Effusion


Some patients in the hospital have fluid around the outside of the lung. This is called a pleural effusion. This is different than fluid in the lung (edema) or pus in the lung (pneumonia).


A lung is like a grape. It has a inner part that does all the work (like the fruit of the grape) and the outer part of the lung like the skin of the grape which is called the pleura. The fluid collects between the inner part of the lung and the pleura.


When fluid surrounds the lung, the lung has less space and it partially collapses. Depending on how much fluid there is and how quickly it gets there, patients with fluid on the lung can have difficulty breathing.


There are a lot of different reasons that people can have fluid on the lung. Fluid can follow injury, an infection, kidney failure, heart failure, liver failure, or cancer. Depending on the cause the fluid may be clear, bloody, or full of pus. It is important to know the cause of the fluid around the lung in order to keep the fluid from coming back.

To figure out what is causing the fluid around the lung, doctors often need to sample some of the fluid using a small needle, this is called a thoracentesis. If the patient is having a hard time breathing, or if there is a lot of fluid, doctors will sometimes leave a tube in the chest to drain the fluid, this is called a chest tube. (see chest tube).


Chest Tube


If a patient has a collapsed lung or fluid around the lung, doctors may need to put in a chest tube. A chest tube is a large tube that is placed through the muscles between the ribs and into the cavity that holds the lung. The tube is then hooked up to a vacuum to help empty the fluid around the lung and to try to “suck” the collapsed lung back up.


When doctors put in a chest tube, they put numbing medicine into the skin and muscles. They often give pain medicine and anxiety medicine to the patient. They then use a small knife to cut through the skin and muscle. This makes a pathway for the tube so that the tube can be placed into the chest. This is not as easy as it sounds and it may take quite a few minutes.


Once the chest tube is placed and the lung starts to expand, the chest tube can be quite irritating. A patient may not want to take a deep breath because it hurts too much when the lung expands with each breath. But, if patients do not take a deep breath, pneumonia can develop. It is very important for a patient to tell the doctors if it hurts too much to breathe so that doctors can give pain medicine to make it so it doesn’t hurt. Sometimes, doctors will even put in an epidural---a catheter in the back that numbs the entire chest wall (just like the epidural that a doctor places to make it so it doesn’t hurt when a woman has a baby).


When the fluid is no longer draining from the chest and the lung is completely up, the doctors will remove the chest tube.


If a patient is on a breathing machine, doctors will often wait to take the chest tube out, even if the fluid is gone and the lung is up. This is because the pressure from the breathing machine can make the lung collapse again and doctors do not want to take the chest tube out, only to have to put it back again.


Brain or Thinking Problems


Head Injury/ Traumatic Brain Injury (TBI)


People who have been in a very bad car accident or who have been beaten on the head can develop serious damage to the brain, which is called “TBI."


When there is damage the brain, the brain swells, just like your finger would swell if you caught it in a door. The brain is different from a finger because it is completely covered with bone. When the brain swells and reaches the edges of the bone, there is no more room for the brain to go. The pressure inside the bone increases and this pressure can cause more damage to the brain. If the pressure gets too high, the brain has no where to go except into the spinal canal. If the brain starts to move into the spinal canal, the brain becomes very badly damaged...this is called herniation.


To monitor the pressure in the brain of someone who has been in an accident, doctors may put a device through the skull into the brain. When the doctors detect an increase in the pressure of the brain, they give medicines to try to reduce the pressure. Things that bother patients, like loud noises, or coughing, can make the brain pressure increase. If a patient has high brain pressure, doctors often ask that you spend less time with the patient, or only visit without touching or talking to the patient.


Usually it takes a week (and sometimes longer) for the swelling in the brain to decrease enough so that the pressure monitor can be removed.


Decreasing the pressure in the brain keeps more brain from being injured, but it doesn’t heal the brain that was already bruised. It can take a very long time for the bruised brain to heal, and sometimes it doesn’t every heal completely.


Some people who have had a serious head injury don't act like they did in the past. They may have difficulty remembering people or things. They often have a hard time controlling their emotions. Many patients have to relearn simple things, like how to dress themselves, how to read and write. Many patients who have had serious TBI benefit by being in a special rehabilitation center.


Sometimes it can feel to family like the person who wakes up is not the same person who was in the accident. It is important to know that the patient is not TRYING to act different. It is hard to keep from becoming angry at patients who act different and who say things they would not have normally said. Very often, families get frustrated and then blame themselves for not having patience. Dealing with serious head injury is very difficult and it is often helpful for patients and their families to be able to talk to other people or families who have been through the same thing.


Delirium


Many people in the hospital become confused and don’t act the way they usually do. This is called delirium. People who are delirious may hallucinate and see and hear things that others don’t see. They can become scared and paranoid. They can feel like their family and their doctors are lying to them. They can also say and do things they wouldn’t ordinarily do---they can be more angry than usual, they can take off all of their clothes, they can refuse to let the doctors and nurses take care of them.


Delirium happens because the patient has been ill, the patient is often on a mix of medicines, and the patient is in a strange environment. The hospital is very different from most people’s regular routine. People stay in bed all day and all night, lights are on during the day and night, people (particularly nurses and doctors) are up during the day and night. Most people do not sleep well in the hospital because they are sick and because they are interrupted a lot when they try to sleep. In addition, people are on lots of different medicines that can make it difficult to remember what happened or understand what has happened.


Delirium is usually temporary. As the patient gets better, the brain will start to get clearer. The hardest thing for both family and the doctors is waiting for this to happen.


Doctors will try to change medicines, change when the lights are on, and change when a patient sleeps to try to get the patient “back on track.” Having family around also can help a patient who has delirium. If family cannot be around, sometimes doctors and nurses will have a “sitter” stay with the patient all the time.


Delirium is very frightening for both the patient and for the family. It is hard to see your loved one act so differently than usual. It may be helpful to talk to your nurses and doctors if you feel frustrated.


Stroke/Brain Attack


A stroke happens when part of the brain does not get enough blood. When part of the brain does not get enough blood, it dies. When part of the brain dies, certain parts of the body or mind do not work right anymore.


There are two different kinds of strokes. One kind of stroke happens when there is a blood clot or plug in the arteries that supply the brain. For this type of stroke, doctors want to get blood going to the brain as soon as possible. If a patient comes to the emergency department very quickly and the doctors are sure that the stroke is not the result of bleeding in the brain from a burst artery, they may be able to give very powerful clot busting medicine to try to break up clots or plugs in the arteries.


Another type of stroke is cause by a burst blood vessel in the brain. For this type of stroke it is dangerous to give drugs that thin the blood. Doctors may need to do special tests on the brain to figure out whether a stroke is caused by a blockage or a bleed.

After a stroke happens, some of the brain that appeared to be damaged when the stroke first happened can “recover.” It can take weeks or even months to know how much a patient will recover after a stroke. With aggressive physical therapy and time to “relearn” how to do things, some patients will make a complete recovery while other patients do not.

To support a patient while we wait to see what recovers, we often have to feed the patient artificially, with a tube that goes into the stomach from the nose or from the outside of the stomach into the stomach. For patients that are having a hard time coughing after a stroke, we also sometimes put a breathing tube into the neck so that the nurses can suck out any fluids from the mouth, nose or throat that could get into the lungs.


Many patients who have had a stroke need to have help and rehabilitation after their stroke. This is often done at places other than the hospital---places that specialize in managing strokes.


Brain Death


People who have had very large strokes or bad injury to the head can develop brain death. Brain death happens when pressure in and around the brain becomes so high that the brain is irreversibly damaged.


When a person’s brain dies, the brain no longer tells the body that it needs to breathe. Without a ventilator breathing for the patient, the patient would die because they would not breathe. However, most patients whose brain’s are injured and who have swelling on the brain are on a ventilator while we wait for the brain to either heal or to die. Because the patient is on a ventilator when the brain dies, oxygen still gets to all of the vital organs. The heart still beats. Blood still goes to the hands, and the hands often feel warm. The body still makes urine because blood is still going to the kidneys.


To the patients family, the patient may still look alive—very much like a patient sleeping on the ventilator. This is very hard on families because the patient often looks no different than before the brain died.


But the patient is not alive. The patient does not move when they are pinched, their eyes do not respond to light, the patient does not cough when we move the breathing tube, and when we “ask” the patient to take a breath by decreasing the work the ventilator is doing, the patient does not breathe. The patient will never wake up. This is not like being in a coma.


To be absolutely certain that the brain is irreversibly dead, doctors will often perform several exams several hours apart to make sure that nothing has changed. When the brain is dead, the patient is declared dead and the life support must be stopped.


Before the ventilator is turned off, the patient’s family will often be asked if the patient would have been willing to donate his or her organs...such as the kidneys. If the patient would have been willing to donate his or her organs, the team may wait to turn off the ventilator until they know if there is a recipient that can use the patients organs.


Making a decision about organ donation when dealing with the death of a family member can be very, very hard. Counselors are available to help families during this very difficult time.


ICP monitor (Ventriculostomy)


If a patient has had severe injury to his/her brain and the doctors are concerned that pressure is building in the head, they will put a monitor in the head to measure the pressure. This monitor is called an ICP monitor.


The ICP monitor is a small catheter that goes into the head through the skull, through a small part of the brain into a fluid filled area of the brain. The monitor can measure the pressure and it can be used to drain fluid to reduce the pressure in the brain. The fluid that comes out of the brain is usually clear but if can be bloody.


Doctors clean the area on the head and then put medicine into the skin and the top of the skull to make it so that there will be no pain there (this medicine is called lidocaine). The doctors then use a small hand drill to make a very small hole in the skull. After this hole is made, the a small tube (catheter) is easily placed through the skull. The brain does not “feel” pain and most patients who need this procedure are in a coma and are not feeling or reacting to pain.


Once the monitor is placed, doctors will monitor the pressures in the brain carefully. If the pressure are too high they will give medicines to try to reduce the pressure in the brain or medicine to increase the blood pressure (this increases blood flow to the brain). When a patient’s brain pressure (ICP pressure) is too high, doctors often want the patient to be very still---they will sometimes induce a coma and often ask that the patient not be aroused or stimulated by visitors.


Halo


If a patient has a broken neck, it is important that the neck not move. This is very similar to if a patient has a broken arm----if the bones aren’t held in the right place, they won’t heal right. Just as a doctor would put a cast on your arm, doctors need to put a sort of cast onto the neck.


One type of “cast” that the doctors can use to hold the neck still is called a halo. It doesn’t look like much of a cast—but it works the same way. The halo is a brace that sits on the shoulders and chest and is connected to the top of the head with a series of properly sized bars.


To put a halo on, doctors must have the right sized bars---the height from the chest to the head. Then, to connect the bars to the head, doctors attach the bars to a “halo” or band that goes around the head. To attach the band to the head, doctors attach pins that go from the bad into the head, just into the skull (the bones that make up the top of the head). When the doctors screw the pins in, they use medicine to numb the skin and to numb the first part of the bone.


Once a halo is on, it usually needs to stay on for several weeks, and often up to three months. When a halo is on a patient, the patient cannot turn his or her head or nod the head up and down. Usually the halo is not painful, but it can be very frustrating because of the way that it limits movement of the head, makes it difficult to get dressed and because, once a patient leave the hospital, it can draw attention from people who walk by.



Loss of Blood Pressure (Shock)

and Serious Infection in the Blood (Sepsis)



Shock


Shock is when a patient’s blood pressure is very very low. In fact, the blood pressure is so low, the doctors and nurses worry that not enough blood is getting from the heart to the rest of the body. When patient’s have shock, there is risk that some of the vital organs (the liver, the kidneys, the brain, the lungs) will be damaged or may die. The more organs that are damaged, the smaller the chances for recovery.


There are many different causes of shock. Bad infections (septic shock), a very serious heart attack (cardio-genic shock), or a lot of bleeding or severe dehydration (low volume shock) can cause very low blood pressure.


While the doctors are trying to treat the cause of shock, they often put a patient on powerful medicines to elevate the blood pressure. Doctors use these medicines to try to prevent organs from dying because there is not enough blood pressure.


Shock is a very serious illness---one of the most serious illnesses. Doctors use monitors, sometimes even monitors that are in a patients heart, to figure out how best to help the patient. When a patient is this sick, doctors and nurses usually recommend that the patient’s family be nearby in case the patient gets sicker.


Sepsis or blood stream infections


Patients who get infections from bacteria in their blood can develop an illness called sepsis. The bacteria can also damage important organs in the body and cause the blood pressure to drop to very low (shock) levels.


An easy way to understand sepsis is to think about a very busy party. At first, the party gets bigger and bigger and more people come, eat and drink. This is what the bacteria do—they get into your body and then multiply until there are millions of bacteria in your blood. Antibiotics are given to stop the party, by killing the bacteria and keeping them from multiplying.


After a large party, there may be damage to the furniture in the house and there is often a lot of trash. In sepsis, the bacteria have often damaged the organs and left trash that can still do damage to the organs even after the bacteria are gone. The bacteria can damage any organ system. Most often, the bacteria affect the heart (causing a low blood pressure), the lungs (making the person require a breathing machine) and the kidneys (making the patient need dialysis).


Other than giving antibiotics, there is very little that the doctors can do to fight sepsis. We just wait until the party is over and then figure out how much damage there is. Sometimes, it can take two or three days to know how badly the patient has been hurt by sepsis. Because so many different organs can be damaged by sepsis, some patients die from sepsis. About one in three people who develop sepsis die from sepsis.


People who survive sepsis are very lucky. But it often takes weeks, if not months, to fully recuperate from the damage that has been done. Often patients who have had sepsis are very weak and require help and rehabilitation before they can return home.


Swan Ganz Catheter or Pulmonary Artery Catheter


Sometimes, when a patient is very sick doctors may need to use a small tube (catheter) to keep track of how much fluid is in the body and how well the heart is working. One tube doctors use is a pulmonary artery catheter (PA catheter), which is also called a Swan Ganz Catheter.


The PA catheter is placed into a central vein and then carefully moved through the right side of the heart into the lungs. Once the PA catheter is placed, doctors can learn about the pressures in the lungs and the pressures in the heart. The doctors can use this information to decide if fluid can be given without flooding the lungs and to decide what powerful medicines need to be given to help the heart and to raise the blood pressure. The PA catheter can be left in the body for up to 5 days—allowing doctors to make minute by minute changes in the medicines that they are giving to the patient.


Although the PA catheter can be very useful, it can be dangerous to put it in. To put in the catheter, doctors must put a large needle into the neck or into the chest, and this can cause bleeding, pain, and very rarely a collapsed lung. The catheter can also bother the heart and lung. Doctors use chest xrays to make sure the catheter is put where it is supposed to be and that it stays where it is supposed to stay. Doctors and nurses look for any sign of infections when the catheter is in the patient and they are very careful (using masks, gowns, gloves and special soap) when they put the catheter into the patient.


Heart Problems


Heart Attack or “MI”—myocardial infarction


A heart attack happens when blood cannot get to the heart. Without blood, part of the heart dies and the heart does not pump as well as it did before the heart attack. Usually a heart attack happens when the arteries going to the heart are plugged with cholesterol or with a blood clot. The part of the heart beyond the “plug” may die.


When someone has a heart attack, doctors may try to unplug the artery to the heart. Doctors try to unplug the artery by thinning the blood. Doctors can also put a small tube into the heart to unplug the blocked artery. To keep the new artery open, doctors will often put a stent, which is much like a spring, into the artery.—to keep blood clots from plugging up an already narrow artery. When more than one artery is plugged, doctors may sometimes recommend that a patient have heart surgery, which is called coronary artery bypass grafting. Because of the amount of time the blockage has been in place or because of other illness treatment to unplug the blocked artery is sometimes not likely to be of benefit. Make sure the patient understands the benefits and harms of each treatment.


If heart attack is really big and a lot of the heart is dying or has died, a patient’s heart may fail altogether. Blood that reaches the heart cannot get out of the heart and it back flows into the lungs and makes it very hard to breathe. When the heart doesn’t beat well, the blood pressure can drop every low. This is called shock. A very low blood pressure can cause other organs, like the kidneys, to be damaged.


After a heart attack, patients need to be watched carefully. As the heart tissue around the blockage “wakes” back up, the heart may not beat the way it usually does. Not normal heart beats are called “arrythmias.” The unusual beating of the heart may dangerous and doctor may need to put the patient on special medicines to restore the normal beating of the heart. Or they may shock the heart into a normal rhythm. The process of shocking the heart is called cardioversion or defibrillation.


Atrial Fibrillation


Some patients in the hospital can develop an irregular heart beat, called atrial fibrillation. Patients who are at risk for developing atrial fibrillation are those who have had atrial fibrillation before, older patients, patients who drink a lot of alcohol, or patients who have had surgery.


An irregular heart beat can be dangerous. When the heart doesn’t beat regularly, blood clots can form in the part of the heart called the atrium. If part of blood clot breaks off, it can cause a stroke. Patients who have had atrial fibrillation for more than a few days need to be on blood thinner to keep clots from forming. This blood thinner can be dangerous if patients have had bleeding or surgery, so doctors and the patient have to think about the risks and benefits of using the blood thinners.


An irregular heart beat can also be dangerous because the heart can beat faster than normal. When this happens, the heart doesn’t fill enough before it beats and the blood pressure can drop.


When a patient has an irregular heart beat, doctors will use medicines to try to keep it from beating too fast or they will give medicines (or even an electrical shock) to try to stop the irregular heart beat so that blood clots do not form and the blood pressure does not drop.


Echocardiography-TTE-TEE


When doctors want to know how well a heart pumps blood, or if there is damage to any of the valves that control the flow of blood into the heart, they may order a video of the heart---this is called a heart ultrasound, or a echocardiogram (also called an Echo). This video is very much the videos (or ultrasounds) that women get when they are having a baby, except this is a picture of the heart, not a picture of a baby.


It does not hurt to get an echocardiogram. The video is made using sound waves. To perform an echo, a specially trained person (technician) will place several stickers on the patient’s chest and arms/legs. These stickers will be connected to wires that record the actual beating of the heart, or heart tracing (see also EKG). After the heart tracings are being recorded, the technician will put some cold jelly (much like Vaseline, but thinner) onto a small wand and then put the wand on the patient’s chest. This wand takes the pictures of the patient’s heart. In order to get a complete video, the technician will move the wand around the patient’s chest, usually under the breast and under the left arm and sometimes near the top of the stomach. When the wand that takes pictures of the heart is placed on the chest, it is called a trans-thoracic echocardiogram (or TTE).


If the doctors cannot get a good enough picture from the wand that is placed onto the patient’s chest, they may need to perform a special echocardiogram called a TEE—or trans-esophageal echocardiogram. This is very much like the normal echo, except that a smaller wand is used and the wand is placed down into the patient’s esophagus—the tube that runs from the patients mouth into the stomach.


Because it can be uncomfortable to have something put down through your mouth and into your stomach, doctors give medicine to patients for pain and for anxiety---the medicine may make it so that you don’t even remember having this test. Because the wand goes into your stomach and because you are given medicine, you can’t eat before this procedure and you need to have someone to drive you home after this procedure.





Cardioversion/Defibrillation


If a patient has an irregular or fast heart beat, doctors may need to shock the heart to put it back to the normal rhythm. This is called cardioversion or defibrillation.


To perform cardioversion or defibrillation, doctors put pads on the chest near the heart. They then deliver electricity to the pads on the chest. This electricity will shock the heart back into a normal rhythm. Doctors try to use the smallest amount of electricity possible to shock the heart back into the right rhythm.


Most people would feel uncomfortable getting a shock of electricity, so doctors give patients pain medicine and anxiety medicine before they give shocks of electricity to the heart. Most patients do not even remember being shocked. However, it it seems the patient may die because the heart is trying to stop, doctors may have to give the shock without giving the patient pain and anxiety medicine.


Sometimes the pads that are used to deliver the electricity won’t stick because of hair on the chest, so the nurses and doctors may need to shave the chest to make the pads stick. Although the stickers have jelly under then to protect the skin, sometimes patients can develop a sunburn-type rash under the pads.


If a patient has required shocks many times, or if the heart has actually tried to stop beating, doctors may put a defibrillator into the patient. This is small box that is put near the collarbone. Wires run from the box through the veins and into the heart. The wires detect the patients heart rhythm and if the patient develops an abnormal heart rhythm, the box will deliver a small shock.


Pacing


Some patients may have hearts that do not want to beat at all or beat much to slowly. In this case, doctors need to provide electricity to stimulate every single heart beat. This is called pacing. If a doctor needs to pace the heart in an emergency, pacing can be done by putting pads on the surface of the chest and delivering small shocks several times a minute. This is obviously uncomfortable to patients. If it is possible, doctors give medicine to the patient to keep the patient from having pain and from remembering having the pacing.


If a pacing needs to continue, doctors can put a wires through the veins and into the heart. These wires can deliver the necessary shocks to the heart—most patients do not feel these shocks. This is called “transvenous” pacing and is only done in the ICU.


If a patient needs permament pacing, a pacemaker is put into the patient. This is a small box that is put into the patient near the collarbone. Small wires run from the box to the heart through the patients veins


Kidney Problems


Kidney Failure or Acute Renal Failure


Many patients in the hospital have problems with their kidneys. Kidneys are important because they filter/clean the blood, removing waste that can be harmful. When kidneys don’t work, the wastes can build up and this can hurt the patient. Also, patients with kidney problems are very sensitive to medicines, and the dose of many medicines need to be changed.


Patients whose kidneys don’t work can become very swollen because they can’t get rid of excess water. It may be hard to breathe because the extra water fills the lungs. When the wastes build up, patients whose kidneys don’t work also can become very confused. In addition to the excess water and confusion, doctors also worry about potassium levels. Potassium is very important for the heart to work right----too little is bad and too much is bad.


Dialysis


When there is too much water, or too much waste, or too much potassium, doctors will use an artificial kidney to filter a patients blood. There are many different kind of machines that are used to filter the blood.


Patients who need dialysis need to have a very large tubes (IVs) put into their veins. The IVs can be put into the neck, by the collarbone or in the very top of the leg near the groin.


There are a lot of reasons that people in the hospital develop problems with their kidneys. Kidney problems can develop if a patient has very low or very high blood pressure, if they have lost a lot of blood, if there is a very bad infection, if they have a heart attack, or if the patient gets powerful medicines that can damage the kidneys.

There are several kinds of dialysis. Some kinds of dialysis take longer than others, some kinds of dialysis are noisier than others.


Not everyone who is put on dialysis in the hospital will need to be on dialysis after they leave the hospital. Sometimes, the kidneys can recover. Often, doctors cannot predict whose kidneys will get better and whose kidneys will not get better. Only time can tell for sure.


If doctors decide that a patient needs dialysis after they leave the hospital, the doctors will look for a more permanent way to get blood into and out of the body (instead of the IV). Doctors can make a connection between an artery and a vein (called a fistula) or they can put an artificial graft between an artery and a vein (called a graft). This creates a high pressure system that can be accessed for dialysis. For either of these procedures, patients need to have surgery and then the area must recover—for several weeks or a few months---before the doctors can use this area for dialysis.


Dialysis does not usually cause pain for patients. However, it stresses the body and many patients feel quite tired during and after dialysis. Gradually, as the body adjusts to dialysis, most patients find that the weakness and tiredness from dialysis is not as bothersome.


"GI" Problems: Bowel, Liver and Stomach Problems


Many people are admitted to a hospital because their GI system (gastrointestinal system: liver, bowel, stomach, esophogus) is not working well. The patient may be throwing up or vomiting, have diarrhea, have pain in the abdomen, a very swollen abdomen, have blood in their vomit or bowel movement... a lot of things that make a patient feel very bad. Sometimes an inability to eat or the loss of so much fluid from vomiting or diarrhea leads to shock (see above). The patient in shock will need to receive (IV) fluids in their veins.


One of the most commonly used treatments for many GI problems is a tube that goes from the nose to the stomach, an NG tube. This tube can be used to remove harmful fluid or air that may be making the patient sick. This tube can also be added to add needed fluids and food.


Many tests are available to find out what is the cause of the GI problem. For example there are special blood tests, regular xrays, and special xrays and scans. There are also ways to look into the stomach and bowel that are described below.



EGD or ERCP:


Sometimes a doctor needs to look into your stomach and into the tube that goes to your stomach (the esophagus). This is called an EGD. Doctors need to perform EGDs on patients who have had difficulty swallowing, have vomited blood, or who have had blood pass in their bowel movements.


Doctors look in the stomach and esophagus to look for a lot of different things, such as stomach ulcers, narrowing in or erosions of the esophagus, tumors, or swollen veins called varices.


To look into the stomach, doctors use a small video camera attached to a light and suction device. They put the camera through the mouth and into the esophagus and then into the stomach. Because people usually gag when things are put through their mouth, doctors will give medicine to make people sleepy. Doctors can use the EGD to take small pieces (a biopsy) of tissue, manage bleeding, and look into smaller tubes draining the liver and pancreas.


Colonoscopy:


If a doctor needs to look into a patient’s colon or rectum, they will perform a colonoscopy. To perform a good colonoscopy, doctors need to be sure that the colon is empty. Before a colonoscopy, patients will be asked not to eat. The patient will also be given suppositories, enemas and/or medicine to drink to make the colon empty all of its stool. These medicines can be a little bit uncomfortable—causing gas and cramping.

Once the bowel is cleaned, the doctors will look up the rectum and into the colon with a camera. Since it is uncomfortable to have something put up the rectum, the doctors will offer pain medicine and medicine to make it so the patient cannot remember the procedure. Once the doctors have entered the rectum, they need to put air into the rectum and colon so that they can move the camera and see all the tissue. During the procedure and after the procedure, this gas will need to escape. Some people can be embarrassed by how much gas they will need to pass, but this is normal and the doctors and nurses expect it.


Removing Fluid from the Belly (Abdominal Paracentesis)


Some patients have problems that cause fluid to collecting in the belly. A lot of different diseases can cause fluid in the belly such as problems with the liver or the heart, infections, and even cancers. In order to figure out what is causing the fluid to collect, doctors need to sample the fluid to send it off for tests. This is called a paracentesis.


To sample the fluid in the belly, doctors find the fluid by either tapping on the belly or by using an ultrasound machine. Once they know where the fluid is, they will make the skin numb with medicine called lidocaine. This medicine is like the medicine that the dentist uses to numb your teeth.


After numbing the skin, the doctors will put a needle through the skin and into the fluid collection. They will then take off some of the fluid. If you are are very uncomfortable and the belly is very large, the doctors may take off a lot of the fluid.


If there is a lot of fluid in the belly, the fluid can come out very quickly after the needle is put into the fluid. It is normal to feel the fluid coming out---it might drain down the side of your belly and even make the bed wet during the procedure. After the procedure, if there is still some fluid in the belly, it can leak out through the hole that the needle made. If this happens, your nurse can put a small bag over the hole to catch the fluid so it doesn’t make you or your gown wet.




Blood Clots...and the Problems They Cause


DVT/Blood Clot/PE (pulmonary embolus)


When a patient in the hospital is laying in bed for long periods of time, the patient can develop blood clots, these are called deep vein thrombosis (or DVT).


When a blood clot develops, it makes it hard for blood to empty from the part of the body where the blood clot is. This can make the leg or arm swell. The swelling canhurt.


If a blood clot develops in the leg or arms, it can break off and go through the heart into the lungs. This is called a pulmonary embolus (or PE). A pulmonary embolus is very dangerous. The blood clot in the lungs can make it hard for oxygen to get into the lungs, so it can make it hard for patients to breathe. Sometimes it can be so hard to breathe, the patient needs to be on the breathing machine. If the blood clot is big, it can also make it very hard for the heart to pump. If the heart and the lungs do not work well, the patient can die.


If a patient develops a blood clot, the patient may be put on blood thinning medicine. Patients on blood thinning medicine have to tested very often to make sure they have the right amount of medicine.


Some patients are at increased risk of blood clots---those who have cancer, those who have had injuries to the spinal cord or to the head, and those who have inheritied blood clotting problems.


SCDs---sequential compression devices


Patients who lay in bed because they are sick are at risk of developing blood clots in their legs. If a blood clot develops, it can make the leg swollen and painful. More important, the blood clot can break off and go to the lungs (this is called a PE or Pulmonary Embolus).


To prevent blood clots from forming, doctors often put patients on blood thinner medicine. If a patient has had problems with bleeding—such as injury to the brain or body--doctors do not want to use blood thinners. In this case, doctors will use SCDs, or sequential compression devices.


A SCD squeezes on the legs every few minutes to push blood out of the legs…this is much like how your muscles squeeze blood out of your legs when you walk. To use SCDs, the nurses will wrap the bottom of the legs and connect this wrapping to a devise that inflates (or puts air) into the wrapping. This air will squeeze the leg.


SCDs are not particularly painful---the legs are not squeezed very hard. However, they inflate and deflate (go up and down) and can be noisy. They can be irritating to some patients. Some patients think it feels a bit like a massage—and actually like the feeling of the SCDs. Once a patient is up and walking, they don’t need SCDs anymore.



IVC filter


A patient who is at risk for blood clots who cannot get blood thinner, or a patient that has had a blood clot to the lung may need to have a filter put into their veins to keep blood clots from moving to the lungs. This filter is called an IVC filter, or inferior vena caval filter.


An IVC filter is like a small basket that is put into the big vein (the inferior vena cava) to “catch” any blood clots that might break off and go to the lungs.


An IVC filter is usually put in by a vascular surgeon or by a radiologist. The doctors get into the big veins using a large needle and the basket (which is collapsible) is put through the needle into the big vein. Doctors make sure the filter is in the right place using xrays.


An IVC filter does not hurt after it is put into place. It may hurt when the doctors put it in because of the needle that has to be put into the neck or into the leg. Doctors use numbing medicine before they put the needle into the vein. If it is possible, doctors also often give the patients pain medicine and anxiety medicine before they put the filter in place.




High Blood Sugar, Hyperglycemia,”Sugar”


Many patients in the hospital already have diabetes. The usual medicines to control their diabetes often have to be changed in the hospital. After leaving the hospital some patients may have different doses or kinds of medicines for their diabetes.


Many patients in the hospital can develop high blood sugars, even if they do not have a history of having had “sugar” or “diabetes.” High levels of stress, certain medicines (such as "steroids") and even certain types of food or nutrition cause high levels of sugar in the blood.


Doctors treat high levels of sugar in the blood, even when it only happens during the time the patient is in the hospital, because high levels can be dangerous to patients --high blood sugars seem to increase the chance of infection and make patients feel weak. Because doctors are concerned about high sugar levels, many patients, even those without diabetes, having frequent sugar testing often by "finger sticks." Patients with high blood sugars are often put on insulin, even if they never had diabetes before.


A person who needs insulin and blood sugar testing in the hospital does not necessarily have diabetes and they do not necessarily need to go home on insulin. As the patient gets better and as the doctors change the medicines the patient is on, the blood sugar values often change and the blood sugar medicine can be stopped.