Rehab chapter 10
A/N – I'm a dialysis nurse and normally meperidine is not used for pain relief with people that have kidney problems because it's toxic to them. In my story, he was started on it but will quickly be weaned off of it. Throughout this chapter and the next two, we're investigating different pain relief methods. My apologies to anybody out there who knows anything about dialysis and the effect it has on the blood levels of certain narcotics. This is not a medical education text. Enjoy! Oh, and meet Tina, his dialysis nurse.
Background music for this chapter: "Flaming Sword" by Duke Ellington, performed by Dr. John on Duke Elegant.
Sometime during his third or fourth day in the ICU (House could barely tell up from down, never mind what day it was) O'Malley and the nephrologist decided it was time to start dialysis. The stuff coming out of his urine catheter could hardly be called urine. House's current mental state could hardly be any more apathetic and he was starting to get a little confused. His potassium had started to rise to dangerous levels and the standard medical treatment they had been using to keep it down wasn't working any more. Dialysis was no longer avoidable. Even though the cause of the rhabdo had been removed, rhabdo had actually already begun to set in by the time House got to the OR for his second surgery. It was hitting its peak right about now.
House was not in any condition to sign consents for anything. It was early in the morning of his fourth day in the ICU. Blythe and John, his parents, had arrived. Wilson, Dr. O'Malley and the nephrologist had updated them but it was really all too much for either Blythe or John to completely comprehend. Watching Dr. O'Malley trying to explain everything to Blythe and John, Wilson was reminded of something House had said before. How can we expect people to understand something after a 10 minute explanation when we don't even fully understand it after years of medical education?
House's cardiac status was so tenuous because of the high potassium that they'd actually already started dialysis pending Blythe and John's arrival. His heart rate had gradually gone down to about 40 beats per minute due to the cumulative effects of too much potassium and some other electrolytes. Atropine and epinephrine would help temporarily but the only permanent fix would be dialysis and, eventually, recovery of his kidney function.
As House laid on the bed, sweating like crazy and mostly oblivious to everything going on around him, the dialysis nurse set up the dialysis machine next to his bed and hooked him up for his first dialysis treatment. House just looked at the nurse with a vacant stare. The nurse said "Dr. House, you're still in the ICU. We're starting dialysis now. You shouldn't feel anything and I'll be right here with you. Your parents are talking to the doctors now."
Things were about to get mighty interesting. The dialysis nurse also worked at PPTH part time, and had heard of Dr. House. She'd never met him, but she had seen him on occasion when one of his patients needed dialysis. He had an awful reputation among the dialysis nurses at PPTH as being a wickedly smart, handsome guy with a major chip on his shoulder about nurses, who never visited patients, and made his fellows do their own dialysis procedures on patients when they weren't adequately trained on how to do dialysis. She'd heard plenty of stories about how the other dialysis nurses had to fix dialysis treatment complications caused by his fellows who were doing the procedure incorrectly. Doctors prescribe dialysis and insert the access necessary for the procedure, but they do not actually do the procedure. It's done by dialysis technicians and dialysis nurses.
But the man lying on the bed in front of her didn't look anything like the monster she'd heard about. He looked like every other sick patient who needed urgent dialysis. He looked just as frightened and overwhelmed as any patient in acute renal failure. She figured once his mental status cleared up, he might actually be fun to talk to. She'd heard he could trade barbs with the best of 'em, and she liked patients with an attitude. The snarkier they are, the more will they have to get better. Patients with an attitude don't give up easily.
As the nurse started his dialysis, she took stock of all the medications he was receiving. House pretty much just laid there like a big lump of clay.
Heparin – should be fine
Ranitidine – should be fine
Epidural meperidine – that'll probably dialyze off
A few standard antibiotics to stave off infection – don't give them during dialysis. They'll dialyze right off.
And so forth and so on. She made her way down the list, making particular note of the meperidine. She'd have to talk with Anderson and House's nurse to figure out what to do if the meperidine dialyzed off. Meperidine doesn't usually dialyze off but when it does, it feels to the patient like a week-long detox session crammed into 3 hours. For most people, that's more shock than their systems can take. Even for patients who need dialysis because of narcotic overdosing, they need to be on something like methadone to ease the withdrawal, and they sometimes need extra doses of it during dialysis. It's kind of a double-edged sword when surgical patients need dialysis. Dialysis very often filters out the narcotic they are receiving for pain relief. His nurse knew that if he began to show signs of increased pain during the dialysis, it would be because dialysis was removing the meperidine, and he would need more. Tina would have her hands full during this first session.
After having had an initial update and having signed the paperwork and the dialysis consent, Wilson escorted Blythe and John in to see their son. John was a stoic military man, a marine. Wilson didn't know too much about him other than the fact that House never talked about him. In fact, House went so far as to avoid talking about or to John as much as he possibly could. House seemed to be on better terms with his mother although even when she called, he still found every reason in the book not to spend much time with her on the phone. Wilson had never really thought about the dynamics of that relationship much until tonight. It was evident by the looks on their faces that it had been a very long time since they'd seen their son. Blythe seemed to need the most emotional support, as pretty much about all she could do was cry. John either didn't seem much interested in, or didn't seem capable of comforting his wife. John seemed much more intently interested in the equipment in the room, saying things like "Stuff seems like top-notch equipment to me" or "Glad to know he's getting A Number One care" or some such meaningless nonsense like that. John also was keenly interested in knowing everyone's credentials, as if only the most highly-credentialed professionals were good enough for his boy. Nobody could tell if he was being truthful or sarcastic and really, it didn't matter. It was clear that John was not capable of providing the kind of emotional support that his wife seemed to need, and that was nothing compared to what his son would need in the weeks and months to come. It seemed like an invisible fort of impenetrable walls went up around John as soon as he saw how sick his son was. Wilson was eerily reminded that the sick man lying in the bed there was just as good at putting up walls. The apple don't fall far from the tree, does it.
The ICU cubicle was too small for the patient, Tina (his dialysis nurse), his ICU nurse, the dialysis equipment, Wilson, the doctors and his parents to remain crowded around his bedside. After the initial shock wore off, it only took Blythe a few moments to stop crying and gather herself. A look of self-assuredness slowly began to appear as she began to take stock of the situation, at least a little bit. John still seemed quite preoccupied with trying to figure out all the equipment and asking everyone how much experience they'd had caring for people with vascular problems like this. He even used the word "vascular", almost as if throwing medical jargon around made him feel like he had some control over the situation. After Blythe had regained her composure, she rounded John up too and said "John, I think we'd better let them get along with their business. I'm sure we're in the way now. We can come back after his dialysis treatment is finished this time." John still looked as if he wasn't quite finished sizing everyone in the room up, but Wilson had already started to assume that maybe that's the way John had always lived his life and maybe he was just showing the only way he knew how to deal with uncertain situations like this. He could sure see where House got his "control freak" nature from. His dad was the personification of the term "control freak".
When Blythe and John left, Wilson, ever the caring soul, followed them out to the waiting room to make sure that they had a place to stay and to see if they needed anything else.
Alone again in the room with her patient, Tina noted something a little different. On his cardiac monitor, his heart rate was looking a lot more normal and regular. The previous long pauses between beats were gone, and as his potassium was no doubt coming down rather quickly, his heart rate picked up to a normal rate. She knew that the next thing to follow the potassium down the drain would probably be the meperidine.
Sure enough, during the second hour of his two hour dialysis session, the focus of all the nurse's labors began to move much more purposefully. Within seconds he grabbed ahold of the dialysis catheter. His eyes popped open with fear as if in a bad nightmare from which he hadn't completely awakened. Alarms started blaring on the dialysis machine because of the catheter being occluded by the patient's grip. The noise seemed to frighten him more. As Tina gently tried to pry his hand off of the dialysis catheter, she calmly told him "Dr House, it's Ok. That's your dialysis catheter. I know you gotta know what that is. You gotta let go of that. You need that. It's Ok. You're almost finished with your first dialysis treatment and you did fine. I'm sure you're in pain. The meperidine is probably dialyzing off. I'll call your nurse to give you a booster." His fingers unclenched from around the catheter. He reached up to her and sighed deeply. "Thank you" he whispered. Within minutes his regular ICU nurse made a repeat appearance and gave him a meperidine booster.
The two hour dialysis procedure went without a hitch. At the end, House was a little bit more alert looking and clear eyed. His heart rate was much more stable. Once the meperidine booster kicked in, he looked at Tina as she was packing up the portable dialysis equipment to be taken back to the dialysis unit. She saw a bit of a conniving look in his eyes, and had to strain a little to hear what he was whispering; "I got $100 says I can beat you in a pissing match." That was, bar none, the funniest thing Tina had heard from a patient in a very long time. Oh, she'd remember this one, she would. When she got back down to the dialysis unit with the equipment, she put her name on the work schedule every day for as many days as they would let her, and asked to be assigned to Dr. House.