When Tumors Go Pop

It was only 11am on Thursday when Howard* came to the hospital to have his blood tests done. He collapsed in the waiting room. He stopped breathing. He was resuscitated and brought to the ICU. I received him from the night shift nurse at 730am. He was on 100% oxygen via a high flow oxygen machine. He was attached to a cardiac monitor which was displaying his vital signs. His breathing rate was 47 breaths per minute. An adult’s normal rate is between 12 and 20. His oxygen saturation was 86%. Normal oxygen saturation for an adult without an underlying disease is above 94%. I did a blood gas test and found that his oxygen concentration in the blood was 7.88Kpa. We want it to be above 10Kpa. In simple terms, though he was on 100% oxygen, his body cells were not receiving it. This partly explained his confusion. He was restless, fidgety and trying to climb down the bed.

A group of specialists to include intensivists, junior doctors, registrars, anesthetists and consultants came around. The night team was handing over to the day team. Dr.Jared* and Elisa* were the lead consultants of the day. My Level 2 patient was heading to level 3. There are levels of patient acuity in the ICU. It helps in management of care and allocation of staff according to the skill mix.

intubated and ventilated patients are level 3, the rest can be level 2 depending on who you ask. You are somewhat safe with a level 3 patient. You know their baseline is ‘extremely sick.’ A level 2 patient is however an illusion. A shifting mirage which can go sideways faster than you could say intubation. They offer a false sense of hope to you as a nurse. You do not know whether they are on their way back to the ward or back to being level 3. Statistics have shown that patients who are re-intubated after a successful extubation have poorer prognosis. With such pressure on your back, you want a level 2 patient to continue being well enough to be stepped down to the ward. Howard was not going to the ward. A decision was made to intubate and ventilate him.

In had not been a primary nurse during intubation. This was my first time. I knew I needed help. The Nurse Team leader passed by and I told her I needed help. I was not confident with assisting during an intubation. I would hesitate. Hesitation is the last thing you need during an intubation. Shadrack*, one of the practice educators in ICU came to help. He is an experienced ICU nurse. His calm confidence during emergencies would make angels blush. He exudes peace, order, assurance. The doctors know him. The consultants adore him. Everyone knows that when Shadrack is around, whatever goes wrong will meet its match in him. Shadrack understood the assignment. I became his sidekick.

Howard was intubated at 1015am. His oxygenation improved but only slightly. His carbon dioxide level on the cardiac monitor was too high. It worried me. I tried adjusting all the parameters Shadrack taught me.  No reprieve. His temperature started creeping up. We tried both pharmacologic and non-pharmacologic methods to bring it down. No reprieve. My colleagues, Angie*, Clare* and Jasmine* helped me keep it together. They administered some medications and ran some tests as I did one thing or the other. They had their own critically ill patients but they spared time to offer me extra pairs of hands. I needed those. They had to push me to have a tea break at 1230pm.

As I ran another blood test at 3pm, I heard all several alarms go off. I had a bad feeling bout my patient. I quickly grabbed the results and ran back only to find one of our consultants, Dr. Jared doing chest compressions on the patient. Ms. Elisa the other consultant was asking for sodium bicarbonate to administer to the patient. Jasmine was dragging the crash trolley to my bed space. Barbra*, Howard’s wife had just arrived in time to see Howard have a cardiac arrest right in her eyes.

He was declared dead at 1515hours. A patient who had driven himself to the hospital the previous day at 11am, had died at 1515hours. I was devastated. The cause of death was later identified as Tumor Lysis Syndrome. I have heard of it but never paid much attention to it.  This is a state where a cancer cell bursts open and releases its contents into the bloodstream. It can occur over days or weeks or it can be as sudden as it happened in Howard. One or many of the swollen lymph nodes in Howard popped open and released whatever toxins they were harboring. There was only so much we could have done to counter the effect.

As his wife Barbra held his hand, she remembered how he beat Lymphoma seven years ago. How the oncologists were happy with his progress only for them to find swollen lymph nodes under his left armpit the size of a small sweet potato. His chest has swollen glands as well and they were becoming increasingly visible.  He was feeling great though. They would beat the cancer just like they had done seven years ago: -Together. She wondered what she missed. I wondered what I missed.

Everyone has a first. The first time you rode a bicycle. The first time you bought a car. The first job. The first meal in a high-end restaurant. The first boyfriend. The first heartbreak. Every nurse has a first too. Every nurse remembers the first time a patient in their care died.  Sa few have died. But none has progressed from level 2 to no level as fast as Howard did. This was indeed my first.

It was my first time to learn that Tumor Lysis Syndrome can easily take a life. This is when one or several cancer cells burst open releasing all their toxic substances into the bloodstream. This is what took Howard’s life. This is what caused his cardiac arrest and respiratory failure.  In a nutshell, when tumors go pop, everything else stops.

*Not their real names