Mylee's ECT, Part 2: Seizing the Day
Doctor Kari was not what Danice had expected; from outside, through the one-way window, she looked much more stern…and taller, Danice thought with a suppressed laugh.
The doctor was walking over, a broad smile on her face. "Hi, I'm Kari." Her handshake was firm, her skin soft and warm.
"I'm Danice. Thank you for this opportunity, Doctor." Danice returned the handshake.
The doctor shrugged in a friendly way. "Not at all. It's you I should thank, for your interest. And please, it's 'Kari'. How is your initial rotation going?" She smiled again, glancing once at the monitors as she pivoted to return to the equipment.
"Very well, thank you. Jen…" she motioned to the senior nurse, "…has been kind enough to run me around to several departments. Earlier this week I did a day in the Autonomic Lab, which was fascinating."
Kari looked at Jen with an intimate smile that looked like a wink. "Jen, did they have Danice assist in the Elim Suite?" Almost a laugh. Danice felt goosebumps at the attention on her. It was flattering.
"Ha, you know they did. Diaper changes are always on The List for newbies!" Jen said, and they laughed softly. Danice blushed.
"Danice, if you were fascinated by Autonomics, you will love it at SMC." Kari winked at her. She knew that Danice was already a high performer - there weren't any other kinds that made it into the Nursing Rotation.
Jen broke the spell with business. "Electrophysiology is the next stop on Danice's rotation, Kari, and I knew that she'd want to be part of this." She looked over at Danice, who was focused on the patient on the gurney, whose face was turned away from them as the room was arrranged.
Kari nodded, her demeanor shifting into more formality. "Absolutely. I'd like you both to meet Mylee." Stepping to the side of the reclined mobile gurney, Kari laid her hand gently on the young woman's bare arm. Danice and Jen walked over to the other side, seeing Mylee reclined rather limply. Danice glanced up at the one-way window through which they'd initially glimpsed the patient, wondering whether Mylee knew it wasn't a real mirror.
Mylee was undressed, with a light paper drape covering her torso. She wore a bouffant - they seemed to be on almost every patient she'd seen at SMC so far - and a standard-issue hospital diaper. Reminds me of Autonomics, Danice thought. Kari had Mylee hooked up for an ECG and BP monitoring, and the ECT pads were obvious above the patient's heavy, glazed eyes.
"Hi, Mylee, my name is Danice." Danice leaned in toward the patient, kindly.
Mylee slowly grinned, lifting the nasal cannula slightly with her cheekbones. "…hey, hi." A soft-spoken response. Her voice was small and light. Partial sedation?
"Mylee is here today as part of a study to validate a new development in cranial electrotherapy for mood treatment. We're working on an approach to ECT with real-time patient interaction, aiming to improve outcomes and shorten cycle times." Kari spoke as if reading from a research paper. Danice got the sense that she had spoken that line a lot.
"That's totally new, isn't it?" Danice asked.
"So far," Kari nodded. "We're still learning, with help from folks like Mylee." Hearing her name, Danice thought she saw Mylee smile spontaneously into the room. "The interaction should, in practice, allow us to tailor each treatment to address specific mood changes and respond to patient impressions. We're just diagnostic right now, not in a treatment effectiveness study just yet."
Jen looked at the monitors, then down at Mylee. She was watching her breathe. "Kari, can you tell us a little about the sedation methods you're using?" Danice couldn't tell whether Jen was asking questions for Danice's benefit or her own. It was a truly fascinating treatment to learn about.
Lighting up, Kari began to speak animatedly. "Of course! We're using a method that pretty much gets us twilight sedation, and adds partial paralytics for patient safety. We call it 'Level Two plus'. Patient awareness and communication is central to the treatment, but with consciousness and mobility comes the risk of discomfort and stress. So we're working with an IV cocktail sequence that produces partial paralysis and some dissociation, but keeps Mylee able to respond and communicate. It's possible to use an epidural and local nerve blocks, but that is more invasive and isn't always necessary. I'll also pre-oxygenate and administer a respiratory relaxant. Today, it will be nitrous."
"Doct…er, I mean - Kari," Danice blushed, "…is the diapering a mitigation against the sedation effects? Are you worried about bladder control?"
"Yes, we've seen it in several study participants. There is some involvement with the parasympathetic response during administration of the cranial current that we don't see with full-sedation ECT. It's an active area of research. For Mylee, as this is her first time, she'll be diapered for her comfort."
Mylee stirred, and looking at Kari, reached down to the exposed diaper. It was labeled with SMC branding and size markings. She laughed lightly. Kari patted her gently on her shoulder.
Danice looked at Mylee, suddenly small among all the equipment. "Kari, if we'll see 'Level Two plus' sedation today, what will the monitors be telling us?"
Kari glanced briefly at Jen. "An excellent question, Danice. We don't expect respiratory depression with this sedation, but the monitors are a precaution because of the experimental nature of the treatment. In addition, I will use her cardio-respiratory response to gauge the intensity of the induced seizure."
"Will the seizure not be visible?" Danice asked. This was all totally new.
"Ah, well, with partial paralytics, it may be. That depends on the patient, we're finding. But it's not like the movies, I suppose I can say." Kari explained. She looked at the monitors, down at Mylee. "I think we're ready to begin. Mylee, sweetie, are you ready to work with me?"
Mylee closed her eyes briefly, then opened them. It was like a slow-motion blink. "…yep." She nodded once, partially, and her gaze drifted to the side.
"Great, here we go. Jen, would you be so kind as to mask her down? Danice, I'm going to have you attend to her vitals, ok?" Kari drew a drape from a tray, revealing two syringes.
Both nurses moved to their stations. Jen was preparing a clear padded anesthesia mask connected by a long ribbed hose to the anesthesia ventilator assembly. Danice watched from her position abreast the cardiac monitor stack. Mylee's vitals were stable, though already showing the effects of her pre-sedation.
"Mylee, I'm going to have you breathe deep for me, okay? Here's the mask." She nodded to Jen. "Just relax and take deep breaths." Jen pressed the soft padded mask onto Mylee's face; the soft edges sealing themselves over the cannula tubes, which she would wear the whole time. "Jen, we'll do five minutes of O2, then switch the nitrous in, ok?"
Jen nodded, stroking Mylee's forehead gently. The mask circuit hissed softly.
"Danice," Kari said, lifting a syringe. "BP, please."
Danice pressed the START/STOP button on the monitor and Mylee's cuff began to puff and strain. A whirring sound accompanied the changing numbers on the screen. Danice watched as Mylee's heartrate sped up a bit. Was she nervous? She thought. If so, it was only visible in the vitals; the patient's face was itself a mask of serenity.
With a series of audible puffs, clicks, and a long beep from the monitor, the cycle concluded. "117 over 76, doctor." Danice said clearly. "HR 82, Resps 14."
Kari nodded. "Thank you. She's ready. Mylee, I'm going to give you some medication now. Here we go; you're going to feel a little cool, then warm. Keep breathing for me, sweetie." Kari pushed the plunger, the syringe emptying into her IV port. Mylee sighed a little - or, perhaps a moan? Danice couldn't tell. "One in." Kari swapped syringes, paused. "Danice - again, please. Let's do a 3 min repeat."
Danice started a BP cycle, set the auto repeat to 3 minutes. Soon: "125 over 85, HR 80, Resps 16."
"Jen," Kari said. "Please switch to the nitrous circuit, and we'll start with 50% nitrous in the mix."
Jen fiddled with the adjusters, and Danice saw the float-gauges bobble up and down a bit. "Done, doctor." Jen watched the gauges closely.
Mylee made a "mmmmmhmm" sound in the mask.
"How are we doing, Mylee?" Kari asked while placing the syringe's cannula into the IV port.
"Mmmm," Mylee moaned weakly.
"Mylee, honey, are you looking forward to helping me today?" Kari patted her on the shoulder more forcefully than before. "Resps, Danice?"
"Jen, cap ok?" Kari was looking at Mylee's eyes, which were still open.
"CO2 is normal, in the limits. She's ok." Jen said.
Mylee stirred slightly. "Wanna…wanna help - you." Danice could see her smile in the clear mask. It was almost endearing.
Kari smiled. "Great, Mylee, I'm so glad. Here we go, you're almost there." She plunged, and another bolus of anesthetic cocktail entered her bloodstream. "Two in." Kari looked up and addressed the nurses. "With the nitrous at 50%, this last cocktail should place her into partial paralysis. She'll still be responsive, but you can see that it takes a bit of work to get communication. Today, I'm just working on simple interactions with low cranial currents. Mylee is only at the beginning of her study." For clearer visualization, Kari pulled the paper drape from Mylee's chest, revealing her bare torso and additional ECG leads below her breasts.
For a minute, the three women staff members quietly monitored their patient, watching Mylee's petite chest rise and fall in concert with the life sounds from the monitors. Mylee's eyes remained open, her respirations slowing somewhat. Her blood pressure came up to 130/87 and stayed there. An effect of the cocktail? Danice thought.
Kari spoke into the clinical stillness. "Jen, let's dial the nitrous to 0%, and you can unmask her. Danice, can you check her for incontinence?"
Danice reached over to the gurney as Jen was stowing the mask and hoses. "Mylee, I'm going to check your diaper, sweetie; ok? Just relax for me." Danice heard the faintest sound of aquiescence from Mylee as she pressed lightly on the crotch padding of the diaper. The crinkling and puffing was a familiar sound after Autonomics. "She's dry, doctor."
"Thank you." Kari was tapping info into her digital chart tablet. "I think we're ready to proceed. Jen, I'll ask you to be ready on the ECT controller. Danice, can you stay on vitals for me?"
Both nurses sounded agreement and Jen moved to the ECT machine. It was an unusual design, different than Danice had ever seen in training, but still had a large red button labeled 'TREAT'.
"Kari," Danice spoke up, curious, "…are you using standard cranial currents?"
The doctor was leaning down, using a penlight to examine Mylee's pupil reaction. She nodded as Mylee squinted in response. "No, this is also part of the study. We're using very small currents, about 10% the standard, but pulsed in a unique way. The pulse pattern is shaped to deliver energy that lowers the seizure threshold - gets us effective responses with less energy. We also want shorter seizures, with less risk of patient discomfort. Today it's a very small current indeed, just to gauge Mylee's sensitivity. We might expect some seizure behavior, but it's possible we won't see anything at all."
Danice took a breath. This was the most excited she'd been since she arrived for orientation. She almost giggled in anticipation. Keep it cool, Danice, she thought to herself, glancing at Mylee's vitals to center her attention.
"Mylee, I'm going to place this in your mouth, just like we talked about, ok?" Kari held a disposable blue bite-block, and with a deft motion, she lowered Mylee's jaw with a gloved hand and slipped the block into place. "Don't bite down, sweetie, just let it rest in there."
"Mmmmph," Mylee sighed. Danice saw her finger barely lift, as if in acknowledgement.
"Nurses, we're ready. Clear the patient. Danice, vitals."
"BP 131 over 88, HR 77, Resps 13." Danice hadn't taken her eyes off the monitor.
"Mylee, here we go. Breathe in, sweetie, breathe really deep." The block in place, Mylee started to inhale through her nose. "Jen, treat."
Jen pressed the red button, and it clicked as the ECT machine began a warbling, two-tone low alarm sound. It lasted for about two seconds. As Danice watched, Mylee seemed to vibrate, although she couldn't tell whether she was imagining it. The patient's thin frame shuddered, once, and she stirred as if arching her back in slow motion. But still barely moving.
Then the machine stopped its alarm tone, the cranial current ceasing. Suddenly Danice realized that Mylee was making a sound, herself, that had been hidden under the alarm.
"Nnnnnggguuuuhh…" she trailed off, just at the limit of audibility. It was honestly quieter than the QRS tone from the vitals monitor. She was moaning.
"That's a seizure," Kari spoke aloud, placing her hand on Mylee's chest as if to feel her movement. Vitals?"
Danice had to shake her head to clear it. "Ah," looking quickly, "BP 135 over 91, HR 93, Resps 21. These are…stable numbers." Mylee was in a kind of plateau. Her eyes were open, somewhat wider than before, but she didn't look panicked.
"Mylee, sweetie, you're doing great." Kari spoke loudly, while patting the patient's chest, as if to get her attention. "Can you feel the tightness we talked about?"
The three women waited for a beat, arranged around the gurney, watching Mylee seize in slow motion. "Unnngghh…hmmm…yyeeaaah," Mylee managed through the bite block.
"Any pain, Mylee?" Kari asked, looking up at the monitors. Except for a rise in blood pressure, Mylee's vitals were stable, although elevated.
"Mmmm…nnn…uhhh - noooo." Mylee breathed in sharply, suddenly, then a deep exhalation. The monitor beeped, then booped deeply.
"PVC," Danice called out. "Make that two."
"Decels…another seizure, maybe. Different, though?" Kari's voice was questioning.
Then Mylee moaned, almost…in relief? The familiar sound of rushing liquid followed, Danice suddenly realizing. "She's voiding, doctor." Placing her hand instinctively on the diaper, she felt it filling. "It's strong." Mylee moaned again, with a note that sounded almost embarrassed.
Kari watched as the next BP cycle showed a hypotensive shift. "Yup, that tracks. Thank you, Danice; Mylee seems to have a sensitivity here. How is her lower tonality?"
Danice felt Mylee's femoral area and groin for distention and muscle engagement. "She's relaxed."
"Mylee, sweetie, you're doing great. Don't worry about that at all, it's all normal, honey. Just breathe for me, okay?"
"Mmmmkkkkhhh." Mylee finished wetting herself, too weak to protest. The diaper was yellowed and swollen between her legs.
Kari kindly patted Mylee's chest, craned her neck to look into her patient's eyes. "I'm going to take out the bite block, Mylee, can you open your mouth for me?" Mylee slowly lowered her jaw, and Kari pulled the foam block out. Mylee drooled innocently down her chin as the block was withdrawn. "There we go. You did great, honey!"
Mylee smiled, almost absent-mindedly. Kari spoke up again, looking at the monitors. "What's my name, sweetie?"
"Mmmph. Docl…Kar-i." Mylee mumbled.
Patting her chest again, Kari straightened up. "Nurses, thank you for your assistance. There's a lot more to learn, as you can see. Remember, this was only diagnostic for us - the current and pulsation was obviously enough to cause a threshold seizure, which is good data. And desirably short, as well. But no real treatment for Mylee today. She may not even recall the details when she recovers. But she did very, very well." Making sure she spoke that last part loudly enough for Mylee to hear, she looked affectionately at her patient.
Danice looked tenderly at the young woman, as well. "Was her incontinence a surprise?"
"Yes," Kari said, "…but only because I expected it upon sedation, not during seizure. That was certainly something to look into. Mylee's hypotensive shift was a sign that we might want to place a Foley before the next session, though. Her vitals today might not represent the seizure alone." It seemed Kari was digesting the results in real time, and Danice was defintely getting excited at the prospect of being around during this much discovery.
"Kari," Danice began, "I have to say, I'm terribly interested in helping out further. Thank you so much for this."
Kari smiled. "Of course, and it's you both I should thank. And Mylee as well!" Kari looked expectantly at Jen, who had been taking in the exchange, silently. Danice realized that this wasn't her first session with Kari.
Jen grinned. "Well, we've got a few more stops on the rotation. There's a lot to show Danice, and a lot for her to familiarize herself with." That definitely sounded like a senior nurse's gentle command, Danice thought. "But we'll be back, if you'll have us."
"Any time. We're learning every day," Kari said. "Mylee, we're going to get you cleaned up and back to your room, okay?"
Mylee nodded, more alert every second. She was starting appear self-conscious, aware of the monitors on her body. "Ca…n, caaan you taake…" she lifted her arm with the cuff inflated tightly.
Kari, kindly, "Oh, not yet, sweetie. Just a bit longer, as the medications wear off." The doctor looked expectantly at Danice.
Well, Danice thought to herself, I've got the recent practice. "Mylee honey, I'm going to change your diaper and get you cleaned up, okay?" Danice asked, beginning to pull on a closure tab.
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