Thursday, August 27, 2015

A new post!

Late post! God, I hate working a huge raft of shifts in a row. Out of the last ten days I’ve worked eight, and tomorrow I go back for two more. You know what’s great? Having more than one day off in a row.

I came back the next morning and discovered that the supply-room coffee was even worse than usual, with a bitter, rancid edge that made it damn near undrinkable even with a carton of milk stirred into it, a petty-theft latte for the desperate. I coughed down a few gulps and rinsed my mouth in the sink, promising myself Starbucks as soon as I could get break coverage.

I don’t usually blow cash on Starbucks. I live a block from an independent coffeeshop that makes lattes to wake the dead, the kind of perfect espresso miracle that makes you sigh with relief every time you take a sip. It’s hard to get excited about the over-roasted stuff you get at the white-people-with-yoga-mats chain. God, I’m such a fucking snotty hipster these days I piss myself off.

(A week or two ago my husband and I dug an old, perfectly functional turntable out of the trash, bought a cheap pre-amp from an audiophile wizard of our acquaintance, and rifled a local yard sale for a few albums—ELO’s ‘Out of the Blue’, Tubular Bells, Neil Young’s ‘Heart of Gold’, and some Fleetwood Mac or other. We have been offending the neighbors ever since. This is probably a huge improvement over our usual evening soundtrack of Star Trek reruns, Bill & Ted’s Excellent Adventure, and Conan the Barbarian. The point is, we are now the worst kind of dad-flavored hipsters and should be euthanized for the good of society.)

But I can be as hipster as I want on my own time. When I’m working, I am 100% down for peppermint disks from the crystal dish in the conference room, PB&J in a paper cup with saltines, and the hospital cafeteria’s Clam Chowder Fridays. I have dumpster tastes and raccoon appetites and I belong out back of the Waffle House instead of in a high-tech facility for healing. Starbucks is outright classy compared to my workin’ self.

So it was quite a blow to realize that I was getting a pt who’d just landed fifteen minutes ago after having been airlifted from a smaller, rural hospital. Landing a critically ill pt—too sick to be managed by the local teams—meant I would be glued to the bedside, monitoring and giving meds and managing drips and performing all the little tasks that are so hard to adequately describe because they’re so boring. No time to go get Starbucks.

But if you can’t get coffee, adrenaline will do. I nabbed my stethoscope from my locker and headed down the hall with my pulse already picking up, seeing the cluster of transport techs and docs and nurses and other beasts swarming around my pt’s room.

She was eighteen. She had given birth four days ago, a healthy baby, and despite having severe pregnancy-induced hypertension during the last few months, she had seemed to be totally in the clear after delivery. PIH and its later stages, pre-eclampsia and eclampsia, are typically resolved by the end of pregnancy as simply as throwing a switch—as far as I understand it, which is honestly not very much. I’m an ICU nurse, with a cardiac focus. I don’t do uteruses.

And I guess I didn’t understand PIH very well, or else nobody informed her PIH it was supposed to resolve with delivery. In the few days since her baby had popped out, the woman had developed heart failure associated with the fluid imbalances of late pregnancy and the massive hypertension of uncontrolled PIH, became fluid overloaded because her damaged heart couldn’t move fluid effectively, and developed pulmonary edema from the backed-up water. On top of that, her hypertension had reached critical levels at the rural hospital, and she had started having seizures.

So she came to us with a magnesium drip to keep her blood pressure low, a propofol drip to keep her sedated, an endotracheal breathing tube so we could mechanically ventilate her, and a foley catheter with the bag filled to bursting as she responded to the diuretics they’d given her. The mag drip, in particular, made me uneasy. We don’t infuse magnesium for hypertension on the ICU, preferring nitroglycerin and other vasodilator drips, but apparently it’s the front-line treatment for PIH.

And it works. A few minutes’ pause on the mag drip while we hooked it up to our own IV pumps, and her blood pressure started to crank up to dangerous levels again. Boluses from the propofol bottle sedated her deeply, but had almost no impact on her blood pressure, which set my teeth on edge because I’m used to being careful with the white stuff lest I bomb my pts’ pressures. (Some facilities don’t allow RNs to bolus propofol at all, for this and several other reasons. It has a bad reputation since Michael Jackson died of it; it lowers seizure thresholds in certain cases, and raises it in other cases; and it’s thick and white and fatty and can raise a pt’s triglycerides very quickly.)

Pausing the propofol drip for transfer, on the other hand, woke her up good and proper. With the mag drip infusing, her blood pressure stayed right in the 130/90 range (a handful-of-salty-chips pressure elevation, nothing to worry us), but she woke up immediately and sat bolt upright in the bed. She rolled her eyes like a panicked horse until the whites flashed, and worked her mouth frantically to try to spit out the breathing tube. This is sort of a recurring nightmare for ICU nurses: we all fear being intubated and not sedated, waking up with the tube in, confused and tied down and struggling to breathe.

It’s not like we don’t have people wide awake and cooperative with the breathing tube in. More than a few pts don’t even get restraints, or we’ll put on soft bracelets with enough slack to just remind them that they shouldn’t grab the tube (but allowing them to write, shift their weight, and scratch their balls at will). But that first waking-up needs to be careful and relatively gentle, to avoid PTSD from the sheer terror of being captive and bound with your airway occupied. And some people have severe anxiety, which is completely fucking understandable, so we keep them knocked out pretty hard until it’s time to pop the tube.

In this woman’s case, she was totally fine when propofol’d out of her mind, but that first waking up was much faster than any of us expected, and it wasn’t terribly gentle. You could see, watching her struggle to focus as we poured the milk of amnesia into her veins, that she had a hundred things to ask us, and no way to communicate any of them.

Of course we reassured her that her baby was fine, that the baby was with the pt’s mother in the waiting room, that the baby was doing well and so was she. It was enough to get her through the next thirty seconds while the propofol put her under. Once she was unconscious, we called for a mother-baby doc and nurse consult, ordered a fresh bag of magnesium, and set to clearing the used linen and tagalong trash from her transfer bed.

I started my assessment. Every pt on the ICU gets a full head-to-toe assessment, every four hours, rain or shine, day or night. It’s become more common recently to let people sleep at night instead of shaking them awake and prodding them until the computer is happy, a practice of which I whole-heartedly approve. But since I work during the day now, I do my assessments like clockwork: on admit, on transfer, and every four hours. Between major assessments we do focused assessments, which emphasize the systems we’re most concerned about. Everything is systematic and very thorough, and since assessment is the nurse’s most powerful tool, we are exceedingly serious about it.

An assessment begins with a general look-over from the door. Is the pt awake or asleep? Breathing hard? Sweating? Grimacing? Agitated, somnolent, pleasantly engaged, crying? My pt was well-sedated at this point, sticky with swift-drying sweat, still tense in the knuckles from the aftermath of awakening. If she were awake, I would progress to the next step: does the pt know her name, the date, where she is and why? Can she follow simple commands, pay attention while I recite a list of letters and squeeze my hand when I say ‘A’? None of this was appropriate for her, and I had already got a pretty good look at her responsiveness to various stimuli. I called her name, and her eyes flickered—good enough for now.

If she were in neurological distress, with a head bleed or a clot-busting drip, I would be assessing her much more closely, with one of a cluster of focused assessment tools. Since she was intubated and sedated, I assessed her with the RASS tool to document her level of awakening, fudged a CAM delirium assessment with a promise to come back and re-assess later once she was through the initial period of sedation, and ticked all the boxes in her GCS tool chart to indicate her responsiveness to various stimuli.

After that, I look at HEENT—head, eyes, ears, nose, throat. Surprise, there’s a tube in there. Welp.

Cardiac: heart rate steady, no weird beats. Listening to her heart with a stethoscope, I heard a third sound between the usual beats, the sound of all the extra fluid in her body interfering with her valves’ closing. Blood pressure fine, as long as the mag’s running.

Respiratory: lungs sound a little crackly from the extra fluid. Swollen all over—even the soles of her feet were ballooned out. (When the swelling goes down later, all of her skin will peel and wrinkle.) Oxygenating just fine, and with the ventilator pushing her breaths in, she’s shedding CO2 pretty well, as evidenced by the end-tidal CO2 being measured by the machine each time she exhales.

Gastrointestinal: a nasogastric tube, clamped, taped to her nose at fifty-six centimeters. Good bowel sounds. Abdomen swollen, but no more than the rest of her body.

Genitourinary: a foley catheter, which I had already emptied twice—a great sign, since fluid overload was her chief issue. As for the reproductive part… I hit that wall in utter confusion. I racked my brain for leftover memories from nursing school: the vaginal discharge would be lochia rubra, a normal presentation; the uterus would be palpable somewhere below the belly button if I pressed on her belly, and should be midline and firm with no mushiness or asymmetry. Fuck if I know how to tell what a uterus feels like at baseline.

Also, her breasts were incredibly distended and painful-looking. I asked her mother, who was sitting with the baby in the waiting room, and she confirmed that the pt had been breastfeeding. “It’s really important to her,” she said. “Is there any way we can, you know, have the baby nurse while she’s unconscious? To keep her from drying up her milk?”

I told her that, honestly, I had no idea, but that I would call the mother-baby center and ask one of their nurse practitioners to consult on her case. Twenty minutes later, the NP showed up, well-dressed and elegantly groomed, with a breast pump and a much-thumbed reference book she used to double-check all of the medications on the pt’s medication list. None of them were a risk to nursing infants. “Just pump her breasts every two to four hours,” she explained to me, “and save the milk in the bottle for the baby to drink.”

Man, if there’s one thing ICU nurses don’t want, it’s ANOTHER task to be performed every two to four hours. Turning pts is time-consuming enough. And yet, I figured life is hard enough for an eighteen-year-old single mother without losing the option of free baby food.

I think I’ve mentioned that I love weird ICU machines—beeping, flashing, pumping monstrosities that take six hours of classroom training to manage effectively, maybe with built-in EKG readings or a touch-screen panel that has to be overridden every hour or so when the pt starts to crater. I am, like many other ICU nurses, a gadget addict.

And yet that breast pump completely defeated me at first. I held it like a live snake covered in human shit, and even after I figured out how to use the flappy valve things to keep a seal and how to hold the funnel parts so that they held the right part of the nipple, I got so freaked out watching the expansion and contraction of the nipples in response to pressure changes—not to mention the needle-thin spouts of white milk spraying into the funnel neck—that I had to take a little break and focus on ordering a new bag of mag.

But as I continued learning to use the breast pump, the weirdest thing happened. I’ve known since I was very small that I wanted to have children, but I’ve also known that I wanted to wait for a while, and I spent most of my twenties in soul-stripping fear that I would become unexpectedly pregnant and have my life, career, and body wrecked before I had a chance to prepare. As the oldest of five kids spread across ten years, a child of a home destroyed by mental illness and religious fear, and a survivor of poverty and neglect brought on by shitty family planning, I have both longed for a healthy family of my own and dreaded the impact of children on my life—and feared that my personal issues will someday ruin my children’s lives.

It’s a strange place to be, psychologically. Lots of conflicting emotions and hopes and regrets, none of which I really know yet how to reconcile. Lots of times where I look at somebody’s new baby on facebook and wonder why I feel absolutely nothing, and lots of times where I look at my best friends’ kid and feel all the chemicals in my body going insane at once.

So as I pumped breast milk and bottled it and passed it to the pt’s mother to feed to the baby, all in a weird fugue state of combined relief—this nightmare of hospitalization and separation from a newborn is not mine to suffer—and envy, that this woman has her child waiting for her when she gets well, and I go home to my husband and my cat.

Kinda fucked up. I do envy my pts sometimes. Some of them have the most beautiful, loving families; some of them are so unreserved and uncomplicated in their desperation for more time with their parents. Some of them have lived amazing lives of travel and action and accomplishment. Some of them are simply happy, despite everything. And sometimes, even with the cancer and the heart failure and the tragedy and the pain, I wish I were them, just to have those things.

But the third time I set up the breast pump, as my pt started to come around from her stupor in response to the decreased load on her heart, I realized she was watching me collect her milk, and made eye contact with her.

“Your baby is doing really well,” I said. “None of your medications are affecting your breast milk, so we’re bringing it to her to drink. You’ll still be able to nurse her when you feel better.”

Her eyebrows relaxed; her head sank back against the pillow. Even propofol hadn’t brought her so much comfort. I thought really hard about that, the next twenty minutes while I finished gathering her baby’s next meal, about being intubated and desperately ill and still hoping for the normalcy and delight of having a baby to feed after recovering.

I was nursing her so that she could nurse her baby.

There are different types of care, even in the ICU. I felt really weird about the whole thing; I was so far outside my element that I hardly understood half the things I was doing. I am not accustomed to performing care by rote, by sheer mechanical direction; I like to know the rationales, the evidence, the best practice methods. Right now, though, there wasn’t time for me to know everything, no opportunity to research further, just a set of half-understood tasks and the necessity of human connection. And the knowledge that, even if I didn’t do everything perfectly and didn’t even understand everything that was happening, I was taking care of my pt as she needed to be cared for.

She might need physical therapy when she stops needing my care. She might have lingering heart failure. She could be working through this shit until her kid is in grade school, who knows? But when she’s done being intubated, which I’m guessing won’t take her more than twenty-four hours, she’ll be ready and able to nurse her baby. Even if everything else is fucked up, that one thing will come out all right.

And, I dunno, I thought a lot about my own hypothetical future offspring, and about what things might be worth the damage I’ll inevitably do. And I think, when the time comes and my husband has finished aircraft maintenance school and we’ve killed off a little of the debt of tuition, when I get my IUD pulled out and start thinking about baby names, I’ll be okay.

(Baby names so far: Alma, Vashti, Enoch, Margaret, Emrys, Sagan, Phillippa, Ra. God I pity my children. My husband proposed Hypatia; I proposed Hatshepsut. We already have a cat named Erasmas, nicknamed Raz, named not for the book-loving philosopher but for the hero of a Neal Stephenson novel that meanders in the middle. Okay, maybe we better not have kids.)
Anyway, after the L&D doc came and examined her—turns out palpating the fundus is just a matter of abdominal massage + knowing what the fuck you’re palpating for—I got an order to take her down for an MRI. This is, in some ways, much like a CT scan, and in other ways nothing like it. For one thing, an MRI doesn’t irradiate you—but it does take forever and it shows different things, depending upon how you apply contrast. Also, you can’t take anything metallic into the MRI chamber or it will get yanked up against the magnet and piss off your MRI techs, just like, so bad.

So we got her ready to take down to MRI. She was starting to really wake up, making eye contact, mouthing words around the tube, at least half of which words were clearly “baby.” I told her, of course, that babies aren’t allowed on the ICU, that it’s dangerous for them to risk being so close to so many gross bugs while their immune systems are still half-baked. And then I got an idea.

If there’s one thing I do well, it’s making sure my pts are clean.

I scrubbed her all over with chlorhexidine. I changed the bed; I took sterilizing bleach wipes to the whole frame. I changed her IV lines to make sure they were sterile. I talked to her mother in the waiting room, and then I scrubbed myself to the elbow and put a sterile drape over her belly. I took her restraints off, trusting her to leave the tube in place and cooperate while I kept her partially awake.

Then I and the respiratory therapist rolled her and her ventilator and her IV pumps out into the hallway, past the nurses’ station, past the entrance to the waiting room. We stopped, and her mother brought her baby and laid her on her chest.

For thirty seconds, she cried and held her baby, her wrist restraints released, her propofol drip paused. The ventilator hissed and squeaked, forcing air into her swollen lungs, keeping her alive against the day she would breathe for herself again. The baby squawked, shuddered, came to rest; she sobbed until the ventilator complained.

Then I gave her another propofol bolus, and she slipped off into a dream, and her mother took the baby and retreated to the waiting room while I loaded her onto the elevator and took her down to the MRI.

The MRI is a challenge. You have to shift the pt onto the narrow stretcher that goes through the scanner, and pack them in tightly—no small trick when your pt is swollen with something like fourteen extra liters of fluid. You also have to get them comfortable enough to chill out while you feed them into a tube the size of your mom’s vagina—roomy enough to admit an adult human body whole, but still tight enough that you wish the whole time there was a little bit of lube.

Also, if you have a drip running, you have to put it in a special MRI IV pump. The pumps are approximately one hundred thousand years old and made without metallic/unshielded electronic components. Plus, when I got to the MRI chamber, the fucking IV pumps were broken.

Yeah. Here I got a pt with a propofol and a mag drip keeping her a) comfortable and b) safe from strokes and seizures, and a chunk of dead plastic that beeps at me impotently like a smoke detector with the battery clandestinely ripped out. (Not that I regularly burn food and have to pull the battery out of my smoke detector. In the mean time, let me give you my recipe for kick-ass ribs.)

(No, for real. Get yourself a rack of pork ribs, rip the parietal membrane off the inside, don’t bother trying to rip the osseous sheathing off the bones even though it kinda sorta attaches to the parietal membrane, sprinkle it with salt and wrap the whole thing in foil, and cook it at 225F for eight hours while you sleep. All the cartilage will melt into gooey gelatin juice and be easily edible instead of chewy and gross, and the runoff can be stirred into your favorite BBQ sauce and brushed over the ribs, then broiled at 500F until it turns into a crackly, sticky mess. You can eat the bones, if you cook it for more than eight hours—they decalcify and just dissolve in your mouth. This shit is so good you don’t even know. Just put a foil-lined pan underneath, or your oven floor will fill up with drippings and smoke like a Frenchman until you clean it two weeks later like the gross slob nurse you are. Not that I would do this.)

I considered, for a moment, just pausing the drip. She’d stayed calm long enough to hold her baby; maybe she could hold still long enough to handle the MRI? Maybe. Not really. I paused both and within minutes her blood pressure skyrocketed and her eyes rolled in distress.

So I did a thing I trained to do in nursing school, the semester before I learned about vaginas and all the horrible things that happen to them when a ten-pound human rips through them. I did dimensional analysis.

I pulled out my phone, out in the MRI tech room by all the computers where you can get as close to your pt as possible without magnetically bricking your portable internet machine. I did, I swear to sweet tiny Jesus the baby, suckling at his mother’s breast, math.

So there ya go. Where will you use this stuff after high school? You’ll use it here, with an eighteen-year-old mother gasping on a stretcher, with two sterile syringes Y-lined into your IV drips, drawing from the bag and pushing one milliliter at a time, counting seconds for two hours while you push proprofol and magnesium at pre-calculated rates to keep her blood pressure stable and her terror at bay.

You’ll use it one tiny push at a time, while the seconds stretch to minutes, while you remember that the surest way to make time drag is to watch the clock. You’ll use it while the MRI bangs and shrieks through your earplugs, with your head rested up against the plastic so you can reach the IV and your back twisted so your arms can twist further, with your fingers tingling under the magnetic field where they cross and the iron in your blood forms a bridge for the invisible force of technology to meet and reinforce itself. You’ll use it until your foot goes numb and you can’t hear, and the thing that keeps you upright is the sound of your pt breathing through a plastic tube and the thought of her baby, waiting for the next bottle of milk, the shadow and image of the children you may yet have yourself if you ever get over your nightmares and your memories and let them have a chance to survive your slipshod parenting, the way you survived yours.

When I pulled her out of that passage, calm and quiet with a blood pressure that wouldn’t offend tissue paper, I felt like I was the one giving birth, being born. Maybe that’s a bit cheesy. We do, though, envy our pts from time to time. And we do have hope for things beyond the ICU, for ourselves and for our pts, and for the people who we will never see on the ICU, who will escape it by inches or miles and live their lives ignorant of the breathing tube and the propofol drip.

And when I brought her upstairs, I might have missed my lunch and both of my breaks (which is a fucking big deal, okay, I’m lazy as fuck and I always get my breaks), but despite the uncertainty of mother-baby nursing and the exhaustion of MRI pump-impostership and the weirdness in my own brain, but I felt like my pt had given me something I could never have given her. I am indebted to her; does that make sense? I hope I was able to pay her back. (The next day she was extubated, transferred to a medical floor, and allowed to nurse her baby. She went home later that week. She was absolutely, totally fine, except for needing a while for her heart to recover. She was all right.)

Also, during this shift, a transport team showed up from an long-term acute care center, and they picked up my abdomen guy from so long ago. They took him away to be cared for somewhere else. He waved his hand at me and two other nurses as he left. He’s not himself, not exactly; but there’s some of him left, and who knows what else he’ll gain in time? Maybe we saved something. I hope he does well. I will miss him.

We don’t always have good outcomes. But I don’t feel too bad about these two.

(Even if I made them both, embarrassingly, all about me. Well, I’m a selfish person. I’ll just deal with it later, when I wake up tomorrow and go to work, wishing I’d slept instead of writing.)

Monday, August 24, 2015

Adjusting my plans!

Okay, so, that week off was desperately needed. I hadn't realized, but I was writing a ridiculous amount of verbiage, and it turns out that writing that much was a recipe for burnout.

Plus, I feel like you guys are starting to get the feel for ICU patterns: a little heart failure here, a little COPD there. Unusual things happen sometimes, between the cardiac caths and respiratory failures, but there are only so many times I can explain pressure imbalances or tell you that titrating vasoactive drips is both boring and strenuous.

So here's my new plan: I will post one shift report per week, based on the most interesting shift I worked, with extra coverage for any interesting short bits that happen on the other days. This will give me time to write another post every week-- a story, a piece of patho, or even an extra shift report.

I'll post the shift reports on Tuesdays, and the second posts on Fridays (Thursdays would make more sense except that my work schedule has me wrapping up a major week of work on Thursday nights, and I am usually dead by that point).

And yes, I will write up that one awful story. The first time I wrote it up, I wasn't satisfied with how it turned out-- clean-edged, internetty, and all about the shock value. I would like to rewrite it, and see how a year or two has aged it in my head.

See you all tomorrow night!

Saturday, August 15, 2015

I meant to post Friday, but I was so tired after that last shift that I fell asleep on the sofa and didn't wake up until 1030. Today is my one day off, and I got about half a shift written, so I will try to finish it up tomorrow after work and post it then.

Boy I tell you what, working more than four shifts a week is a profoundly bad idea for my sanity. Definitely gonna have to find a better balance so I can make the writing work.

Wednesday, August 12, 2015

Week 9 Shift 1

I showed up late for work by about five minutes, having lost track of time while I was standing in the shower performing my usual morning devotional of cursing, groaning, and ordering myself grimly to wake up, come on, you can do it.

Any time I’m late to work I sort of creep in from the staff elevators and try to sidle up behind the group report cluster without being seen. No luck this time—a bright-faced unfamiliar nurse called out: “You must be Elise!”

Turns out I was precepting today. Okay. Surprise?

Maycee has moved on to another preceptor—each new nurse gets two days with each preceptor, to make sure they get a good variety of teaching methods. I like precepting and am pretty good at it, but everyone learns differently, and I have precepted more than one person who wasn’t really meshing with my style and needed someone a little more methodical and hands-on. Today I would be precepting Anne, who loves airplanes and hiking and pictures of gross wounds, and who was very patient while I poured half a carton of milk into a cup of ditchwater coffee from the supply room dispenser, then thousand-yard-stared my way through the first half of it before my brain came back online.

Our pt was a tall, strikingly pretty older woman who had been very active and independent before she fell last night, smacked her head on something, and developed a huge head bleed—a subdural hematoma. There are several different types of common head bleed, and this is not usually the deadliest, but an SDH can really wreck your shit.

Brain-case bleeds are typically classified by where the bleed occurs in relation to the different membranes that cover your brain. Different types of vessels run at different membrane levels; the epidural space, outside the dura mater (epi = on, dura = the specific membrane), has arteries, so bleeds out there are quick and high-pressure and extremely painful and exceedingly dramatic. The subarachnoid space, between the arachnoid membrane and the pia mater, is where ruptured aneurysms bleed into, so you can imagine that a subarachnoid hemorrhage is hard to ignore.

But the area just under the dura mater, the subdural space, is largely venous, so bleeds there are low-pressure and typically happen because of trauma. You knock your head and it hurts, sure, but after the initial tissue trauma stops being painful you think everything’s fine. Meanwhile, there’s nothing to put pressure on that venous bleed inside your skull, so it just oozes and oozes until it’s slowly blown up a giant blood blister inside your skull and crushed your brain. Hours can pass before this happens—long enough for you to imagine that the nausea and dizziness aren’t related to your skull smacking against the fridge door when you fell. Long enough for you to take two aspirin (a blood thinner!) and go to bed.

We’re not sure how long this lady was bleeding into her brain before her family found her.ShHe was tucked nicely into bed with a bruise around her right ear, totally unresponsive but still breathing and maintaining her heartbeat on her own. She was brought to us in an ambulance, and the neurosurgeons immediately hauled her down to the OR, performed a craniotomy to drain out the blood, and sent her up to the ICU to see if she’d get any of her brain function back.

That was yesterday. Today she’s not really doing much of anything. She’s getting pain medication through an IV drip, but no other sedation, because we really want her to wake up. She takes a lot of pain medication at home for an old back injury, and since she’s post-surgical, we don’t want to give her no pain control, or she’ll have to deal with a cut-up skull and a bad case of opioid withdrawal all at once.

Yes, your body can go into withdrawals while you’re unconscious. Your body can even experience pain and other warning signals while you’re totally out of it, and react locally and systemically. Doctors who place arterial lines on deeply sedated pts often deaden the area with lidocaine before inserting the line, not because the pt might wake up from their induced coma and yank their hand out of the way, but because the artery might spasm as it’s stabbed with the needle, and it’s hard to advance a line into an artery that’s clenched down in pain.

This was visible with my pt in that, when we paused her low-dose fentanyl drip, her blood pressure skyrocketed. Even though she didn’t flinch when we brushed her corneas with a tuft of cotton, her body was still able to interpret what had happened to it as Very Bad and was reacting accordingly.

On top of the craniotomy, she had two other problems. One, she had (of course, and you probably expect this by now) vomited after becoming unconscious and inhaled some of it, so her lungs were starting to look ARDSy; two, she had developed rhabdomyolysis during her period of total immobility, and her kidneys were clogged with dead chunks of broken-down muscle.

I’ve mentioned that it takes very little time for the body to lose mobility if it’s not exercising. It also takes very little time, all things considered, for your muscles to start to decay if you lie around motionless. Dead muscle chunks rip free and float in your blood, clogging up in your kidneys and poisoning your whole body bit by bit. This is called rhabdomyolysis. It can also occur with extreme overuse of muscles—I had very mild rhabdo once after my first time ever snorkeling, because I was desperately out of shape and swam around paddling all day even though my legs hurt, and I ended up with tan pee and painful kidneys and a full day of lying in bed crying over my destroyed calves, followed by a doctor being extremely stern with me. Trauma and crushing injuries, electrocution, and chemical destruction of cells can all cause rhabdo as well.

Of course, working on the ICU, most of the rhabdo I see is secondary to either CrossFit-style over-workouts or to immobility after a pt has a stroke or a bleed. They come in with kidney failure from the clogging, nitrous waste toxic buildup pickling their brains, gross brown piss from all the myoglobin spilled out of broken muscle cells, and often intense muscle cramping if their muscles ever get any function back.

Anyway, it being a full 24 hours or more since this woman’s brain was decompressed, with the beginnings of ARDS puffing up her lungs and her kidneys ravaged by rhabdo, her chances of surviving are miniscule, and almost nothing if one counts quality of life. Her family is loving and supportive, but really struggling with the onset of grief—they think that loss is still a possible future, a fate that might yet be averted, rather than a thing that has already happened while they were sleeping two nights ago. Even if she doesn’t die of this, she will never be the same person. Her CT scans show diffuse white patches in her brain, indicating brain edema, which in turn betrays dead brain tissue.

Her thighs have blistered up where she was incontinent that night. Over the course of the shift the blisters ballooned, then popped, then oozed. We put in a consult to Wound Care, slathered the sites in antibiotic ointment, and covered them with non-stick foam dressings. These foam dressings—padded, slippery, clingy rather than adhesive—are a mainstay of the hospital; every pt who is transferred to the ICU gets one put on their butt first thing, barring only pts in good enough shape that they wear their own pants, and pts who are shitting too hard to keep anything within blast range of their sphincters. It seems ridiculous, but the padding and friction relief protect skinny, protruding tailbones almost as well as proper butt flesh.

And speaking of shitting… our lady suffered from chronic constipation, and a few doses of stool softeners unlocked her guts beautifully, filling the bed with everything she hadn’t been able to poop in god knows how long. It was an uncommonly aromatic buttflood; people complained to the first-floor ER desk about a foul smell in the elevators that serviced our third-floor lobby. Anne, to her credit, didn’t complain at all as we cleaned and mopped and contained the flood, even though the stench was incredible.

We learned about soap-and-water bed baths. We learned a lot about them. You can only get somebody so clean with wet wipes; eventually, you have to switch to a nice soapy tub of warm water and a handful of towels.

Some of my coworkers don’t believe in soap-and-water baths, for some reason I will never understand. If my pt has crusted-on shit stuck to their butt hair, I’m not going to waste four packs of wet wipes before I start running the sink. Mavi, on the other hand, will wipe until shift change, examining each wipe for diluted shit streaks and chanting: “No yellow! No yellow!”

I think the idea is that there’s no risk of the wipes being dipped back into the soapy water, contaminating everything you wash from that point on. But come on, dude, just don’t double dip.

After that we sat in the hall for a bit, shell-shocked, and pretended to chart while staring into space in various directions. The intensivist dropped by and asked us what we were doing, and I said I was mustering the energy to walk up to the front nurses’ station, so he grabbed the back of my rolling chair and pushed me up the hallway, mock-scolding me the whole way about laziness and entitlement while gently bashing me into every piece of equipment on the way. I laughed until I nearly puked. Then I picked up a potassium replacement from the tube station, where the pharmacy sends all the medications up that don’t fit in the med cabinet, plopped my butt back in the chair, and superciliously snapped my fingers at the intensivist for a ride back.

He just kicked the chair’s rolling base and sent me spinning about ten feet down the hallway, then chased me down the hallway to show me an iphone picture of the sushi he had for dinner last night. He is that kind of intensivist: dramatic, hardworking, willing to jump in and help, humorous, and capable of snapping your head off if you fuck something up. He’s a bit of a diva. Of course we all adore him for it.

His unusually high energy levels were explained shortly after that: he was getting all psyched up to put a pt in the rotoprone bed. He loves rotoprone beds as much as I do, for what I’m assuming are similar reasons, and when we have a pt in a roto he basically moves into the workstation outside their room and can’t be dislodged for love, money, or premium sushi.

I love rotoprones because they are huge, complicated, labor-intensive, bizarre to look at, incredibly effective, and accompanied by a host of other techniques and medications that keep you hopping all day. Rotoprones are, essentially, giant padded beds into which a person can be packed, then rotated face down and cradled in the packing cushions while the bed rocks them back and forth to allow their lungs to drain. It is incredibly effective at supporting pts through the ravages of ARDS, although it really needs to be initiated early in the ARDS process to have its full effect.

In the rotoprone, for instance, pts need to be pharmaceutically paralyzed. This requires us to shock their wrist nerves gently at various intervals to ensure that they’re paralyzed enough to prevent oxygen-gobbling, but invisible, processes like shivering. We want them to be able to twitch a little, but not a lot, so while we’re adjusting the paralytic drip and watching their adrenal glands for signs of deficiency (a paralytic side effect), we’re also zapping them with a little box and writing down the results.

There will be inhaled epoprostenol to reduce the high-pressure imbalance in ARDSy lungs; maybe a Lasix drip to drain off excess fluid; high doses of sedatives and pain control medications; almost certainly pressors, which must be adjusted constantly in real time. Insulin and sugar must be balanced precisely. Electrolytes skew wildly in every direction, and must be corrected. Careful skin maintenance is required to prevent pts from developing pressure ulcers on their faces or having their nipples scraped off by the endless rocking; rectal tubes and foley catheters drain waste to keep it from sloshing into the bed; the angle, speed, and Z-axis tilt of the bed must all be adjusted constantly to drain vulnerable areas of lung and then return the burden of oxygenation to less-vulnerable areas when things start to destabilize.

It’s an incredibly complicated and fascinating piece of equipment. It would have been really neat to orient Anne to it, and let her try out her new ICU chops on something that complicated and crazy. But we already had our cranie lady, so we helped move the roto pt into their new bed, then returned to our own caretaking.

The family watched her lying there with drawn, distant faces, no longer searching her face for any flicker of life. They had been holding her hands and chatting about happy memories; now they sat on the couch in the corner and sagged against each other like empty pillowcases, grim and gray and exhausted.

They were realizing, of course, that she won’t come back. It’s an awful thing to face. It can only be fought off for so long, and when it catches up to you, it’s like suddenly realizing that you haven’t slept in years and all the happy things you thought you remembered were just hallucinations brought on by lack of sleep.

It’s not always this way. Sometimes, even after people start to realize that something is gravely wrong, their loved one recovers at least some measure of their prior function. The truth is that it’s very, very hard to assess someone’s prognosis in that first forty-eight hours, because the injury isn’t yet complete, and we can’t tell when the recovery really begins. It takes patience, at a time when all you want to do is intervene and save their life. It tempts even neurosurgeons to unfounded optimism and pessimism, to superstition and MRI augury.

But the injured brain is a locked room with no windows, and all of its identical doors lead to different places; and time is medicine, and hope and grief are each their own excuse for being.

A little before shift change I went into the break room and caught the intensivist watching Fox News and heckling through a mouthful of instant oatmeal. “My husband and I are going to overthrow society and shit on the Bible,” he goaded the newscaster. “And when you get sick you won’t care because I control the antibiotics!” I backed out of the room without comment. I’ve seen a lot of people come onto the ICU, especially in Texas, and try to dictate which races and ethnicities and sexual orientations are allowed to take care of them. I’ve noticed that, as their condition degenerates, they stop giving quite so much of a shit. It’s hard to keep up a good bigoty froth when you can’t fucking breathe.

Anyway. I heard today that Martha’s family declined the autopsy, which I fully understand, because all medical signs point to her having died of a pulmonary embolism. A clot most likely formed in her arm or her leg and then migrated into her lung, cutting off blood circulation to her air supply—her increasing irritability overnight, the suddenness of her demise, her recent history of dehydration and broken bones, and her PEA arrest all point to the likelihood of this. And, honestly, given that she was on the ICU under constant monitoring when she died, there is nothing else we could have done to prevent it.

Sometimes people just, you know, die. Sometimes even the ICU can’t save them.


I think, after this week, that I’m going to take a week or two off while I recalibrate my goals and try to make them realistic. I hadn’t realized, starting out, that this blog would quickly result in my writing hundreds of thousands of words about my life, or that I would start to feel burnout only a few months in. As it stands, I haven’t had time to pursue things like podcasts, pathophysiology posts, responses to comments, or even dumb nattering in my common internet hangout spots. I would like to see about making a book out of this blog, which would require time for editing and rewriting and creation of new material; I am also working all of the shifts I write about, often back to back, often more than three per week.

So I will post tonight, then Friday night, and then I will take a week off of regular posts and see if I can wrangle a more realistic schedule and set of goals that will keep the good stuff coming without draining my writing reservoirs dry.

It really helps that you guys are so supportive and wonderful, and that feedback has been so constructive in both positive and negative ways. I feel like I’m just starting to develop as a writer, and keeping this blog has shown me a lot of areas in which my medical knowledge is frankly in need of growth. It’s also encouraged me to dedicate myself more fully to compassion and empathy in my pt care, knowing that I am holding myself even more tightly accountable than ever before.

This has, so far, been an incredibly encouraging experience, and I hope I can find ways to keep it rolling for a long time yet.

Monday, August 10, 2015

A night off

It's been one hell of a week-- I've actually worked five shifts in a row this week and am too tired to think straight, and as a result I've almost run out of my backlog of shifts. So I won't be posting anything tonight... back to normal schedule on Wednesday.

Man, who would have thought that writing three to four thousand words three days a week would turn out to be a pretty intense job?

Friday, August 7, 2015

Week 8 Shift 4 (I picked up an extra shift)

I didn’t sleep well after that last shift, and coming back in the next morning was an act of sheer will. This summer has been broiling hot, and I moved out of Texas for a reason, namely that for humans to live in Texas is an act of defiance against the great god Ra, and that if the away team of the Enterprise were to visit Texas in the summer they would refer to this entire world as a “desert planet” and four redshirts would die of fatal solar radiation. I did not move across the continent to a cooler climate so I could sweat like a wrung dishrag all day and all night.

One of my pts was exactly to my tastes: somnolent and needing very little intervention. She lives in an assisted living facility, where she’s mostly independent and hooks herself up to his peritoneal dialysis every night before bed. For the past few nights, though, she’s been “sick,” and hasn’t been running her PD, which has only made her sicker.

Hemodialysis involves sucking your blood out, running it through a machine the size of a Volkswagen that scrubs and washes and concentrates it, and pumping it back in to pick up more trash and water from your overloaded tissues. Peritoneal dialysis is a much less common form of dialysis, and one that doesn’t work for everyone, but which can be much less troublesome if it works right. A PD catheter is inserted through the wall of the pt’s abdomen, and dialysate fluid is pumped in and out, washing toxins from their body and blood through the permeable membranes of their gut. The fluid typically contains sugar, so pts have higher blood sugars on PD, but if it works for the pt… well.

After HD, a pt is typically sick as shit, often confused and shaky, usually weak and exhausted, and frequently nauseated. Regularly dialyzed HD pts tend to go in for a scrub three times a week, and with each round of HD the pt can count on being completely wiped out and useless for the rest of the day. This tends to really interfere in little things like “having a job” and “functioning for a majority of the week,” and that’s before travel time and expenses, interacting with health care staff (I will be the first to admit that we are terrible company), and having to rub elbows with other gross people from your medical community while hoping that they aren’t crawling with MRSA. So if you have the option of doing dialysis in the privacy of your own home, while you’re sleeping, and waking up the next morning ready to go about your day… PD is a total godsend.

The learning curve is a little high though. The pt needs to be thoroughly educated on how to maintain sterility, how to use and troubleshoot the machine, and how to recognize when something has gone wrong. A pt who skips days, who doesn’t follow up on appointments, who cuts corners—that pt is likely to have some really nasty outcomes. A PD catheter is a fast way to fill your belly with all sorts of microorganisms if you aren’t safe and clean with the thing.

Anyway, she had a UTI, which explains both the “sick” part and the reason she, a normally very sharp and independent older lady, made the very bad decision to stop doing dialysis rather than going to the doctor. Those of you with vaginas have likely experienced the burning agony of the UTI, with its bloody boiling lava piss and its ability to leave you feeling like you slept in a dumpster and were picked up by the trash truck before dawn. Sad fact: that shit is a blessing, because you think to yourself: gosh, I have a UTI, I should go get antibiotics. Older women are less likely to have the burning pee sensation, and sometimes their earliest clue to the presence of e.coli in their bladder is the fact that they lose their ever-loving goddamn minds.

That’s right: old ladies with bladder infections go fucking crazy. I’ve seen sweet grandmothers cursing and biting at their descendents, calm-faced knitters who turned into screaming paranoid kung-fu masters, and even a deacon’s wife railing about shit-eating demons crawling into her body and jacking off into her belly button from behind. Forgetting to plug in your advanced medical equipment is kind of tame in comparison.

But hey, no matter how well you handle a pelvis full of creepy crawlies, a few days without dialysis will absolutely make you loopier than a tatted doily, and sicker than shit to boot. This poor lady had no idea where she was or what was going on, except that she was nauseated and unhappy. I came into the room, scrubbing my hands with Purell and offering a chipper greeting, and she groaned and leaned over and barfed corn chowder down her shoulder and off the side of the bed.

There’s this thing, right, where you see or hear someone puking and you feel like puking too, right? I guess the evolutionary advantage is that, if your fellow cave-dwellers start horking up last week’s mammoth, you can get a head start on the mammoth evacuation process before the salmonella poisoning really gets a grip on your duodenum. Being a nurse for more than a few months will completely destroy that impulse. My immediate instinct when someone starts throwing up is to grab the nearest wad of laundry and jam it into the flood to keep it from spreading.

The last time my husband ate bad sushi, I nearly ruined our feather duvet.

God, the best thing about working in a hospital is that so much of the really gross shit gets done where I don’t have to see it. Laundry absolutely saturated with a grainy flood of shit? Put it in the big white bag and throw it down the chute and forget it! Pt took a whiz over the bedrail and threw his dinner into the results? Mop up what you can, and call the long-suffering housekeepers to do a bleach mop. I swear to god, I am not anywhere near this obsessively clean in my daily life, and I am 100% sure it’s because I can’t just page someone for backup whenever shit gets literal. I hope to sweet sainted fuck that the laundry is done by soulless aluminum launder-bots. I have this awful hunch, though, that it’s not, so I’m that picky nurse loser who separates all the plastic padding from the cheap muslin to minimize the necessary sorting before the blankets go in the wash.

But lord almighty, it is so good to be able to get rid of the stench immediately and start forgetting I ever smelled it.

A dose of Zofran and a housekeeping call later, the corn chowder was a distant memory and my pt was sleeping like your dad in church. On her left side, of course. The right lung is set at an angle that makes it easier for inhaled food and puke to slide down the right mainstem bronchus before you can cough it up, which means you want the right side elevated if your pt is at any risk of throwing up and drowning in it. Left side fetal position is often called the “recovery position,” because if you’ve had CPR or had a seizure or been very close to death, you’re likely to throw up at some point in the immediate future and you might not be awake enough to make sure it leaves your mouth and goes all over your nurse’s arm like it’s supposed to. (There are some other benefits to this position too, but my god, how much do you guys really want me to talk about hemodynamics right now?)

My other pt was a gentleman in for placement of an AICD, an automatic implanted cardioverter/defibrillator, which functions much like a pacemaker except that instead of reminding your heart to beat (although some of them do this too), it listens for your heart to have a dysrhythmic freakout and shocks the shit out of its unruly ventricular ass like a neighbor banging on the wall during a party. Pts who frequently go into dangerous dysrhythmias (also called arrhythmias), like ventricular tachycardia, or whose heart damage from MIs and heart failure puts them at high risk of deadly arrhythmias, get AICDs put in so they don’t suddenly die. If parts of your heart are especially irritable or not getting good communication with the rest of the heart, they panic and assume that they’re going to have to run the whole heartbeat show, and start yelling disorganized orders over the actual heartbeat signal. This can cause the whole heart to spasm and lose track of what it’s supposed to be doing, preventing it from actually moving any blood—this is called cardiac arrest. A good jolt of electricity stuns the panicked parts, giving the normal heartbeat a chance to pick itself back up.

That freakout is called fibrillation. The shock is called defibrillation. It’s one of the best tools we have for fixing deadly arrhythmias.

If the AICD shocks you, you know it. We get a lot of pts in because they were having Thursday night dinner when their AICD went off and kicked them facefirst into the meatloaf. Very uncomfortable and sticky.

So this guy had suffered a major heart attack that left part of his heart withered and necrotic—a part that, unfortunately, carried a lot of electrical impulse. As a result, one little area of his ventricles is now deaf to the electrical marching orders of the rest of his heart, and occasionally it gets the idea that it should be doing something and starts barking its own confused orders at its neighbors. He’s gone into ventricular fibrillation several times already, and had multiple rounds of CPR. Fortunately, since he’s been on the ICU hooked up to a heart monitor, we’ve been able to shock him immediately each time; the sticky electric-shock pads that we use to defibrillate him are just staying on his chest at all times now, until the AICD goes in. Because the defibrillation is happening very quickly and he’s only had to rely on CPR for circulation for a few minutes total, his organs haven’t really taken a lot of damage and he’s had good outcomes each time.

Despite three code blues this week with accompanying chest-crushing CPR, this guy is in good enough shape to be sitting in a chair, grumbling because he can’t have breakfast this morning. (No breakfast before surgery—anything in your stomach when you get anesthesia is going to be ejected at some point, and you definitely can’t spit your barf out while you’re unconscious, so breakfast before surgery leads directly to aspiration pneumonia and ARDS.)

When I walked into the room, he greeted me with one of my absolute least favorite quotes: “Hellooooooo nurse!”

Now, I get that it’s meant to be a compliment in some backward way. I understand that if you’re white and male and sixty-five you probably think the highest praise you can give a woman is aesthetic; you might even, if you’ve been reading a lot of noiresque literature, assume that complimenting a woman on her looks is a way of acknowledging her power and independence. But man, I got two problems with pts expressing attraction to me:

--I am pretty obviously not here to look hot. I am wearing pajamas, no makeup, an expression of exhausted patience, and about a pound of someone else’s bile. If you tell me I have lovely eyes with an earnest tone, I will probably accept that gracefully, because while I may check you extra-thoroughly for delirium I can at least appreciate that maybe you have strange tastes. If you react to my entrance like you’ve just been offered a hayjay by Jessica Rabbit, I’m gonna assume that your compliment is the disingenuous flattery of someone who thinks they’re gonna win my favor by introducing a sexual element to our professional relationship, and who intends to milk it for morphine.

--I am far from the most experienced nurse on the unit; I have about five years of ICU under my belt and I showed up for work in critical care two days after my NCLEX with dewy eyes and a trembling chin. But I worked obscenely hard to get where I am, both in my personal and in my professional life, and I am a formidable member of an elite team of life-saving medical staff, and to have that hard-earned accomplishment reduced to a catcall is absolutely intolerable. It reeks of disrespect and inappropriate sexual aggression.

This guy has had several rounds of CPR this week, though, so I gave him the benefit of a quick boundary: “That’s pretty inappropriate, would you like to try a different greeting?”

“Come on over here, little girl, and I’ll give you a different greeting.” Ugh. Uuuuuugh. At moments like this I just remember that I get paid not according to how many lives I save but according to how Disneyland-pampered my pts feel. I picture the dollar signs and bar graphs and ratings, and I grit my teeth and remind my pt that I’m here to provide him with medical care and that I’ll come back in a bit when he’s able to get his behavior under better control.

I’ve learned to be very comfortable with varying degrees of confrontation. I was raised, like many women, to think that the scale goes from “everyone is acting like nothing is wrong” directly to “EVERYTHING IS TERRIBLE” the moment a hint of conflict is introduced. Nursing has taught me that a little conflict in a conversation, like a little pepper on your scrambled eggs, is not only an acceptable thing but even a delicious thing—a thing to be savored, a thing that makes relationships and interactions exciting instead of bland.

I still have the instinct to flee, to placate, to absorb the unpleasantness and smile right through it. And I do keep my smile, and behave politely; but I also have learned to say, That’s super awkward of you, aren’t you embarrassed, and to tilt my head and smile with my eyes and watch that asshole twist.

This was a theme throughout the day. It got very tedious.  

My PD lady continued to vomit, and the doc ordered her an MRI with contrast, which meant I had to take her down to MRI for a full forty-five-minute scan without letting her drown in her vomit. I loaded her with Phenergan, popped a scopolamine patch behind her ear, and borrowed a subglottal suction catheter so I could keep her mouth empty if she vomited while I couldn’t reach her.

Then we moved her down to the MRI chamber and loaded her into the tube. The suction system in the MRI chamber was doing something really weird—like most hospitals, ours has been forced to prioritize its expenses, so some non-critical systems are a bit primitive—so I hooked a big syringe up to the subglottal catheter and stood by her feet as she went into the tube, watching and listening for any signs of vomiting so I could hand-suction her mouth.

The MRI is so loud. I was wearing earplugs and the sound went through me like a bore hole to the terrestrial mantle. If you’ve never heard this sound, I urge you to hit up youtube and have a listen, because no words can do it justice: clanging and crashing, and an all-consuming power-chord thrum of metallic force: DAH DAH DAH DAH DAH. DUM DUM DUM DUM DUM. DRRRR DRRRRR DRRRRRRR.

 It jarred my teeth. My feet ached with the force of the noise. There is an arcane quality to it, a rhythmic intent of pure alien purpose that wants nothing of your sanity and only stops to breathe when it’s finished its task.

While I was in the MRI, my annoying pt was shuffled off to have his AICD placed, and as I returned to the unit the charge nurse told me he would go to the special care unit after the procedure.

So by the time my PD pt was settled, I was ready to take another pt: a craniotomy who had fallen in her home and developed a subdural hematoma. After surgical evacuation of the blood blister inside her skull, they brought her up to me intubated and sedated with a C-collar to keep her spine immobilized. We hoped that the pressure damage to her brain wouldn’t be fatal, but there’s really no way to tell yet, so we’ll wait and see how the swelling goes, and support her medically until then.

She has fake breasts. They are extremely rigid and strangely shaped. The CNA and I noted this and carried on; we see many pts with breast implants and other surgical reconstructions, and I have long since learned that as soon as you start judging a pt for some seemingly voluntary aspect of their looks, you’ll discover that they had reconstructive surgery for cancer or some other thing that makes you feel like shit, and deserve to.

So we made sure that everything on the bed was arranged in such a way that visitors couldn’t see either her nipples poking through the gown, or the unnatural rigidity and wide placement of the breasts themselves. I’m certain that this woman spent a great deal of effort in making her breasts look natural, and it would be cruel and spiteful to let the secret out if she hadn’t already told any of her guests.

It feels very strange to carefully pad a pt’s breasts, let me tell you. I felt a little gross and intrusive. But even if she got them for purely cosmetic reasons, it’s her body, and I wouldn’t leave an embarrassing tattoo out for the neighbors to gawk at either.

The MRI showed no signs of anything wrong in the PD lady’s belly. Thank goodness, she just needs lots of dialysis and antibiotics; we can have her fixed up and home by the weekend. The dialysis nurse dropped by just before shift report and started her on her nightly PD, and I hope that by morning she’s closer to her normal self.

During report, my pt from the last two shifts, the sepsis pt with liver failure, died. An estranged sister had got in contact with us and given us the okay to allow him a natural death according to his wishes, and they turned off the drips, loaded him with painkillers and benzos, and pulled the breathing tube. He breathed on his own for ten minutes, then slipped away gently and comfortably at last.

I am glad for him. He earned his rest.

And after this shift, I’ve earned mine too.

Wednesday, August 5, 2015

Week 8 Shift 3

Day two with Maycee. Somehow she survived her first shift and is back for more, and even looked a little energetic during shift change, which was downright irritating for me because I hadn’t had any coffee yet and felt like a lake of lukewarm shit. Fortunately our unit has free (terrible) coffee in a truck-stop-style machine in the supply rooms, so I was able to get my smack-and-wince dose of caffeine before my ability to feign personhood ran out.

I wasn’t always such a complete caffeine junkie. On nights I rarely ever drank coffee because it fucked up my sleep schedule so badly. Nowadays I can’t get through the morning without my usual half-cup mixed with a stolen mini carton of milk, and I drink the second half-cup cold and kind of stale-milk-tasting later in the afternoon. It’s not much caffeine, but I can’t do without it.

This disturbs me.

Maycee was drinking some sort of sentient green morass out of a Nalgene bottle. It smelled like algae and pineapple. It’s probably some healthy superfood thing I should be drinking instead of a paper cup of two percent and bean tar.

We took report from that one nurse again, the one with the propofol tubing fetish. He was still bitching about the damn tubing. I mean, I have been taken to task by some nurses for stupid things, but by this point I was a little embarrassed for him, especially since the pt we were taking back had been down to almost no levophed at all when we passed him off and now he was cranked up to a stupendous dose, his urine output had been trending downward for three hours with no MD notification, and he looked sweaty and shitty and filthy because apparently that bed bath he’d tried to trick Maycee into was the only bath he got all night.

Night shift nurses do the official bed baths, especially on vented pts. Whatever. I used to be a night nurse and I still have a Thing about my pts being clean. We opened up our shift with a stiff, polite nod to the departing nurse and then a proper bed bath for the pt.

We only had the one this time. Thank goodness—I planned to have Maycee assume all of his care today, and that would be completely impossible if we were running back and forth between pts all day. The neighbor, the humongous guy with diarrhea who was (also) wrongfully intubated, is still doing his thing and I still got to run in every twelve seconds and fix his IV so he could keep getting his sedatives, but we were able to focus mostly on the liver failure/sepsis pt and his increasing needs.

He was not getting at all better, but then again he wasn’t doing anything flashy either. He had high gastric volumes (amount of stomach juice that wasn't moving from stomach to intestine) so we couldn’t start tube feeds; he had lots of fluid in his abdomen so we ended up doing another paracentesis for another 6 liters. Since he weighed in at about 15 liters up this morning, in excess of his base weight, this was less impressive than I could have hoped… but there’s something deeply satisfying about watching all that gooey liquid pour into the suction canister, knowing that we’re cheating the body’s self-destructive excesses and recovering the balance.

A friend of mine observed this recently: a lot of what we do in the ICU is simply keeping your body from killing itself. Many of our natural processes are totally normal and productive at low levels: swelling is an important part of washing out infected or traumatized areas of the body, clotting keeps us from bleeding out, fevers fight infection… but at a critical level of acuity, those same processes become a potential death sentence. Inflammation crushes our bodies, deforms our tissues, drains the liquid from our blood; clots occlude our arteries and contribute to adhesions and use up our platelets where they aren’t needed; fevers cook our brains and organs like gently poached eggs.

Past that threshold, the body can’t heal itself effectively. It’s a last-ditch effort, a forlorn hope: maybe another half a degree will stop the bacteria, and we can rebuild the damage later, maybe, or live without the ruined parts. Maybe a little more swelling will give us the edge against the infection, and maybe we can catch up on blood volume later. Maybe this clot will be the one that heals the damage.

If this one doesn’t work, we die anyway.

But then here comes modern medicine with its antibiotics and other weapons of microbial mass destruction, ready to save the day, if only we can get the body to stand aside and let us do the work. Septicemia? Sure, we have an antibiotic for that—one bug, one drug. Maybe two or three, if we can’t figure out which thing we’re fighting.

But while the vancomycin and piperacillin and ceftriaxone are working perfectly well and the invaders are in fast retreat, the body is still fighting as if it’s alone on the field. So we give drug after drug to support the body through its berkserk phase: liters of fluid to replace losses, pressors to keep the fluid where it belongs, blood-thickening albumin to draw the swelling back in, diuretics to pee it off; steroids to interrupt the cascade of inflammation, blood to counter the dilution and make up for the body’s deficit while it focuses on white blood cells instead of red. Heparin to keep the immobile body from clotting. Bicarb to counteract the acid produced by stressed cells.  Mechanical ventilation to keep the swollen lungs functional and increase available oxygen. Proton pump inhibitors to prevent ulcers and acid reflux while the body is stressed and ventilated. Chlorhexadine mouthwash to keep other germs from crawling down the breathing tube.

It’s insane. If we can naturally produce the antibiotics we need as soon as the germs invade, antibodies with the right markers to identify their enemies immediately instead of mounting a full septic assault, we don’t need any of the other drugs. If we can interrupt the sepsis early, before the inflammation gets out of control and the body’s organs are dying from low blood pressure, we don’t need the ever-increasing volumes of supporting drugs to deal with the consequences of sepsis. And if our bodies can’t control the infection and our doctors can’t keep our bodies in check, we die.

Nothing in nature prepared us to survive things like this. When we save someone in deep sepsis, we are fighting more than germs, more than poisons: we are fighting human history, evolutionary pressure, nature itself.

I have no problem with this. Nature is a bitch. Tumors are natural; epidemics are natural. I am perfectly comfortable fighting nature, as long as we remember that the battle is fought on many fronts and that winning the battle with sepsis doesn’t always mean winning the battle against organ failure, old age, lingering infirmity, and pain. So yes, absolutely, I will fight nature bare-fisted and without shame—but I know better than to gloat over my victories.

All this makes it very hard, emotionally, to care for pts who are doomed. This poor guy never wanted to suffer like we’re making him suffer: he wanted four days, max, on the ventilator, and here we are punching holes in his belly so his weeping, failing liver can get some relief, days beyond his deadline. It’s fucked up and awful and out of my hands. It’s a very American way to die.

Fortunately the ethics committee is involved in this one, and we’re hoping for permission to withdraw pretty soon. Until then, you had better fucking believe I’m blasting him with fentanyl. If he’s got to stick around for this shit, he’s gonna be oped up to the eyelashes the whole time.

Maycee performed most of his care today. I helped with turns and assisted whenever asked, but I let her try things out, make mistakes, and zero out her pressure lines by herself. She did wonderfully, and between chores we exchanged war stories of hospital life.

Having worked on the telemetry unit until now, Maycee’s patient loads have been three and four pts to a nurse, and none of her pts are sedated or on titratable drips. She also worked nights, which means she got to see pts at their weirdest and most whacked-out—a thing I kinda miss, now that I’m days.

She described a group of three sundowning pts whose rooms were unfortunately close to one another, all of whom spent all night yelling at each other. One was a tiny old lady who constantly demanded: “Who’s there? Who’s there?” Another was a little old lady who cursed and screamed for “them” to leave her alone. The third was a developmentally delayed man in his forties who called out for help with almost every breath he took. Two could be redirected temporarily with a bit of soothing company, but the paranoid old lady got worse every time someone came into the room, and the other two responded to her bellowing with a litany of responses: Who’s there? Help! Who’s there? Help me!

All night they kept this up. If one of them fell asleep, the others would wake them back up. Closing the doors increased the screaming—a lot of delirious pts are terrified of being enclosed. Maycee related the charge nurse’s ongoing battle with Bed Control and the shift administrator, as all three pts needed to be close to a nurse station for observation, and breaking them up would involve transferring at least one of them to another floor. Finally the shift admin dropped by to have a face-to-face chat with the charge, observed the noise firsthand, and had transfer orders for two of the three within thirty minutes.

I laughed my ass off, naturally. We’ve all had nights like this, and we’ve all begged distant, uncomprehending administrators for mercy the way prisoners wish upon stars. Any story where someone doesn’t believe a nurse until they see for themselves is a relatable story; any story where the unbeliever is driven mad, splattered with body fluids, or chewed out for their disbelief is a great story. We are nothing if not predictable.

Well. Maybe we’re also bloodthirsty and petty. But we’re predictably bloodthirsty and petty.

I told her about a pt I had in Texas, a woman whose panniculus obscured her legs down to the knee, whose labia majora were distended with edema and obesity to the point that they looked like sagitally aligned panniculi on their own, and whose foley catheter placement was an effort of legend. We used a hammock-style bedsheet hoist to restrain her panniculus and lift it toward the top of the bed—a sheet folded lengthwise, tucked under the hanging gut, threaded through the bed rails on either side and pulled back to achieve a primitive pulley effect.

She had been an uncontrolled diabetic, as I recall, and had a raging raw yeast infection downstairs. I felt fucking terrible for her—she had not been taken care of at all, and was well past the point where she could take care of herself. As we struggled to hold her labia back, she sobbed and hissed with each pressure of a glove against her bleeding, excoriated skin. I had one coworker holding each labe, and I was wearing long gloves and squinting at the bloody, curdled mess of her vaginal vestibule, searching for her urethral meatus—

When one of the coworkers started to lose her grip. “Get out,” she barked, understandably not wanting to grapple with that incredibly painful stretch of skin for a better hold; I got my arm out of the way just in time, as did the other coworker, and the two labia slapped together the way you might clap dust out of a couple of rugs. It sounded like somebody had dropped a fresh brisket on the linoleum. Yeasty effluvium launched from between the folds like taffy thrown from a parade float. All three of us caught a little bit of the splash; I was spackled from my right elbow all the way up to my left ear.

And man, what do you do with something like that? I mean, you can’t really laugh that shit off until you’ve had a chlorhexidine shower and a glass of gin. You sure as fuck can’t freak out and gag and cry and curse, because your pt is right there and no matter how gnarly her vagina is you don’t want to be the dick humiliating a sick woman for being half-eaten by yeast. You can’t even really process it. You assess the damage—did any of it get on my mucus membranes? Do I need to control any secondary drippage? Will I need to get some fresh sterile gloves?—and if you’re not in immediate danger, you just take a deep breath and get back at it.

I do remember reassuring her that I would get her a topical treatment to help with the pain and itching, and that she was extremely relieved once the foley was in and she wasn’t trickling hot urine over her raw, infected skin.

She actually ended up doing pretty well, as I recall. She came back to the MICU three weeks later after a panniculectomy and double knee replacement, and was able to walk a few steps on her second post-op day. I hope that gave her a chance to turn her life around.

After our second-to-last turn, I was tapped to watch a pt down the hall while his sitter was on break. Fifteen minutes of watching a little old guy scratch his balls and ask whose garage he was sitting in? Sweet. We had a great conversation about carburetors, mostly consisting of me having no idea what the fuck a carburetor does and him explaining it to me four times without making much sense, and then he looked me in the eye, lifted his wrist to his mouth to cover a yawn, and pulled out his IV with his teeth. Blood went everywhere. I stanched the flood, paged IV team, and apologized to his nurse for my utter failure as a sitter.

Turned out this was his fourth IV that day. I hadn’t known, when I started sitting him, that his IVs were supposed to be wrapped in an obscuring bandage at all times, and apparently while the sitter was handing off to me he’d unwrapped his line and thrown the bandage on the floor all sneaky-like. Some pts are crafty lil fuckers, I don’t care how confused they are. It’s kind of impressive, really. I don’t know if I could come up with a plan that effective, and I’m not even tripping Haldol-pickled balls on the ICU.

Toward the end of the shift, the abd guy started having a lot of trouble. He had gone down for surgical placement of a tracheostomy and PEG, and I guess he’d been fine for most of the day. During the PEG placement, it seemed, they had insufflated his abdomen—pumped it full of air to allow free movement—and the leftover air was causing pressure issues. He ended up having what I can only describe as an abdominal needle decompression, the way you decompress a tension pneumothorax, and the catheter in his belly farted as they rolled him back and forth to work out all the air.

He nearly coded, apparently. I have never seen anybody react that harshly to insufflation. It’s not like they leave you all blown up. I guess he was just hoarding air—his abdomen is probably a maze of adhesions and scar-pockets by now. Once they decompressed him he was perfectly fine, and even came to enough to open his eyes and move his mouth in voiceless ba ba ba syllables, singing to the ceiling.

Today they started talking to rehab facilities to see if we can get him a bed with Kindred or one of the other long-term care places.

We wrapped up the shift without any more remarkable occurrences, and after running over the day’s events with Maycee, I signed off as her preceptor and gave her full marks for work well done. She will work with a couple other nurses before they start giving her pts of her own. I look forward to seeing how she grows as a nurse. She’s pretty cool.

Regarding the story I mentioned last time, the man and his mother and the cats: I honestly didn’t think this blog would be popular at all outside of the people who already read my forum posts, and they already know that story. I might post it here at some point this weekend, but I want to give a couple of disclaimers:

--It’s definitely the worst thing I’ve ever experienced as a nurse, and hopefully the worst thing I ever will. It’s not the kind of cool story you want to gross your friends out with; I still find it distressing and disturbing and almost sacred in its awfulness, like retelling it is some kind of violation. But I also know that it’s a real thing that happened, and that storytelling is one of the ways we give awful things meaning beyond tragedy, and that some of the things we should fear most are simply hidden from us because they’re too awful to discuss. So I might post it anyway.

--I will definitely have to figure out how to hide it behind a read-more link first.