ventricular assist device

anonymous asked:

Hi! Can you please explain life support more than the basics, specifically someone coming off of it alive and the effects it would have on him/her physically and cognitively?

Hey there nonny! Thanks for this question. Let’s dive in! 

“Life support” is an extremely nebulous term. For example, the term “basic life support” is a fancy way of saying CPR and rescue breathing, while “advanced cardiac life support” is a nice way of saying “extreme cardiac event resuscitation with tubes, IVs, and drugs.” 

Both of those are real-life American Heart Association classes. 

But I have a sneaking suspicion that what you mean by “life support” is closer to “life-saving care in the ICU.” 

That still comes in a great many different forms. “Life support” is the term for the whole care package, the sum totality of all things that are directly assisting to keep the person alive. That might include – 

  • feeding systems via nasogastric (NG) tubes
  • IV drips of life-saving medications, including sedatives if they’re intubated, and those that increase blood pressure such as norepinephrine
  • a breathing tube and a ventilator 
  • a cardiac assistive device, such as a balloon pump (which is a pump connected to a balloon in the aorta), an LVAD (Left Ventricular Assist Device) or BiVAD (BiVentricular VAD) which are pumps in one or both ventricles, an Impella device (similar to a VAD but different technology), Berlin heart (a type of VAD) 
  • ECMO (Extracorporeal membrane oxygenation), aka “pulmonary bypass”; this is a set of enormous IV tubing that hooks up to a big external filter where the blood is allowed to exchange carbon dioxide for oxygen

The character’s “life support” is entirely dependent on what’s wrong and what they need. 

I would say the most common thing people mean when they say “life support” is a ventilator, because it’s extremely common and it takes over a natural and basic function – breathing. 

As for a character coming off the ventilator, this is also an extremely common occurrence! The point of a ventilator is, in most cases, a temporary way to help the lungs oxygenate (with pressure support), and a way to reduce the workload of breathing (which can help other parts of the body). Characters may also be intubated for “airway protection,” meaning that they have a high risk of vomiting and not being able to clear it on their own. 

Coming off the ventilator is a decision made by the doctors about the character’s health. They’ve decided that the character can breathe effectively on their own, or that they at least want to see whether or not they can. 

So they disconnect the vent, deflate the balloon at the end of the tube, have the character take a deep breath, and, as they exhale, they’ll pull the tube out of the throat. They may suggest that the character cough while it’s being removed as well. 

If all goes well the character won’t need any kind of respiratory support, but if they need something, there are a lot of ways to help. Oxygen via a cannula (the little plastic bits you see in noses on TV all the time) helps a little bit, but if they need some pressure support without a vent, a face mask known as CPAP or BiPAP can get the job done. (More recently, high-flow nasal cannula, or HFNC, is coming into style as a way to give pressure support without obstructing the character’s mouth, so that they can eat and speak effectively. HFNC is usually very well tolerated.

After Effects 

You asked about physical and cognitive effects of coming off of “life support.” 

This is kind of hard to say. That’s because a large number of ICU patients wind up with delirium in the ICU and may develop post-traumatic stress even after leaving. ICUs are hard places to be: medications mess with your energy levels and sedation can really cause disorientation and possibly even hallucinations, physically, the character can’t move much; there are constant alarms  everywhere to the point that I don’t know how ICU nurses survive without going bonkers. 

Then there’s the fact that sometimes characters in the ICU are restrained, particularly if they have a breathing tube in and they try to pull it out. Imagine being in pain, unable to speak, and unable to move or request help. That’s a big deal from a psychological perspective. 

Physically, intubation can be traumatic. Vocal cords can be damaged by the tube, leading to difficulty speaking, a raspy voice, etc. Also, artificial ventilation can cause some damage to the lungs, which can cause decreased ability to breathe after the fact, and may require pulmonary rehab. (This is less common than it used to be.) 

IVs can cause bruising and pain. Norepinephrine in particular can cause necrosis of tissue further down the limb, which is why it’s usually given through a central line, a big IV in the groin, clavicle, or neck. Cardiac assist devices, like LVAD/BiVAD, are almost always permanent. Devices like balloon pumps, which are temporary, still leave whopping big holes in the groin and can cause toes down the leg to die due to obstructed blood flow. 

And none of this even talks about why the person was in the ICU to begin with. 

Some characters will get better, leave the ICU, and lead healthy normal lives again. Some will have permanent reminders of what it was that brought them there and how they felt in the unit. And some – too many – will die on the unit. 

I hope this helped! 

xoxo, Aunt Scripty

[disclaimer

anonymous asked:

Do ambulance drivers need any sort of specific training or certification?

Okay. We’re going to talk about this. I apologize in advance if my tone comes off poorly, but this is a misconception that I really, really want to slaughter.

There is no such thing as an “ambulance driver” and the term is downright disrespectful.

As in, I had to take a good couple hours and vent to somebody before I could even approach this ask. That term makes my blood boil.

Ambulances are staffed differently in different parts of the US, but there are 3 main levels of certifications that EMS workers have:

EMTs (Emergency Medical Technicians) are trained to the level of Basic Life Support. They can splint, bandage, do CPR with defibrillators, give artificial breaths with a bag-valve-mask (AKA Ambu bag). In some areas they can give some life-saving meds, like EpiPens for anaphylaxis, and albuterol for asthma, and aspirin for a suspected heart attack. An EMT has about 3 months of training if they took a certificate course, which is common.

Paramedics are trained to an Advanced Life Support standard. We’re the ones who do IVs, EKGs, give drugs, shock patients, We intubate–put tubes down people’s throats. We make field diagnoses. Many paramedics use ventilators, give infusions. We use needles to reinflate lungs that have collapsed. Paramedics MUST be EMTs first. If they take a certificate course, this is 9 months to a year of training in addition to their EMT schooling. However, it is much better to simply get this as an Associate’s degree, with a solid A&P, microbio, and health sciences background.

Critical Care Paramedics are trained even beyond the paramedic level. We work with technologies like isolettes (AKA portable incubators) for neonates, work with Ventricular Assist Devices (VADs) and ECMO (Extracorporeal Membrane Oxygenation, essentially a lung bypass) and medications that are reserved for the Intensive Care Units. We get a lot of clinical latitude to treat our patients.

Flight Paramedics are a specialized type of critical care paramedic who have training that specifically relates to performing medicine in tight spaces at altitude. We study the way altitude affects everything from head injuries to vent settings. We learn about survival and a few more other tidbits specific to working in the aeromedical environment. Most flight programs pair a flight medic with a flight nurse, which is a whole other debate, though in other parts of the world it’s typically doctors with flight medics.

(For any EMT-Is or EMT-CCs or MVOs I left out: I feel you, I see you, you’re important, but I’m keeping it to these 4 just to keep things simple for writers.)

Unless they’re very special, ground ambulances are staffed either with two EMTs, one EMT and one paramedic, or two paramedics, depending on their service. (Volunteer units sometimes roll with a lot of people, but vollies are…. unique, sometimes.) One person drives, the other “techs”–attends to the patient. But while they’re on the scene, it’s a team effort. So the person driving the ambulance is not a “driver”. They are a medical professional. (Of course, in flight services pilots are dedicated to being pilots, because of course they are.)

Overall, I have over 100 college credits to my name; about half are medical, and half are liberal arts. My critical care course and flight medic certification–which is a board certification, by the way–aren’t even factored in to that number. And I’m starting a fellowship in February that’s intended for physicians.

So you have to understand, anon, when you say “ambulance driver” what you’re basically calling us are “medical taxi drivers”. And I know that, somewhere in our history, my predecessors were just that: they drove the ambulance. But EMTs and paramedics have existed as certification levels since the 1970s.

No other first responder gets called by their vehicle. No one points to a firefighter and says “The firetruck is here!”, or points to a police officer and says “the squad car is here!”. But people point to us routinely and say “the ambulance is here!”. I’ve had critically ill patients complain that we weren’t driving them to their hospital–not the closest hospital, but their hospital–while I’m doing interventions to actively save their lives.

There’s a whole set of issues as to how we are portrayed in media, and frankly I don’t want to bore you all with it. The bottom line is that I’m highly skilled clinician with a decade of experience. It hurts

If you have to refer to an EMS worker, and you don’t know our level of skill, just call us that: EMS workers. We’ll be okay with it. And we tend to write REALLY BIG on some part of our uniform what we are, so no one gets confused.

But also try to remember… we have names. Ask. I swear we’ll tell you. We’re people. Really-truly. We have feelings and everything. Call us “sir” or “ma’am”, or “Jim” or “Tara” or “Aunt Scripty”. Call us “Hey EMS”.

Just please don’t call us “ambulance drivers”.

xoxo, Aunt Scripty

A Failing Heart Gets A Hand

This image was made using a specialized computed tomography (CT) scan of a patient’s thorax in 2013. It shows an amazing piece of medical technology called a ventricular assist device

This implanted device was helping a patient with a weakened heart survive while the person waited for transplant. The machine pulls oxygenated blood from the left ventricle and pumps it out through a connection in the aorta, the main artery that distributes blood to the body.

The picture, which won the Wellcome Image Awards this year, was taken to ensure that the device was implanted properly. The blue parts indicate the pump and the white lines are cables connected to it and to an external control unit through a port in the patient’s abdomen. Anders Persson created the image from a series of X-ray slices taken with two different low-radiation energy sources in a process called dual energy CT angiography.

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