Friday, July 10, 2015

Week 1 Shift 2 (technically 6 of 7)

Today started off much better than yesterday. Got my pts back; the little old man with bradycardia recovered overnight and was able to go home by 0930 without having to get a pacemaker. He was delighted and I was also glad for him, not least because getting discharged to home from the ICU almost never happens before lunch. I am a discharge beast though. Spent maybe twenty minutes after his discharge quietly charting in the end of the hallway where the lights hadn't been turned up yet. The suction canister in the empty room created a strange auditory illusion, as if I were sitting near a pond full of frogs all chiming at once. The dim light and weirdly outdoor sound is very soothing and I am relaxed as I drink my first coffee of the day and finish documenting that my patients are still alive and functioning.

The neurodegenerative guy was amazingly improved by the administration of pain meds overnight. Even his swallow was stronger (or else, quite possibly, he's so fucked up that he can't tell when water slides into his lungs and doesn't bother coughing), so tomorrow he's gonna get a barium swallow study-- swallowing barium-enriched fluids in front of an X-ray-- and if he passes that he can eat again. Crossing my fingers for you, dude.

Also got a PICC line in him, which is a long IV that goes all the way up your arm into your heart, allowing us to give you much stronger and more concentrated medications without injuring or burning your veins-- things like potassium, which is very painful given through a peripheral IV, and total parenteral nutrition aka IV food. Palliative Care came by and talked to his brother about his end-of-life wishes and the possibility of transferring him back to his adult family home on hospice, where he can live out the rest of his days with his treatment focus being comfort rather than recovery. Physical Therapy has a hard time working with him because he has so much pain. 

He apologizes every time he asks for anything, or anything is offered to him. He is pathetically grateful and wary in a way that reminds me of an abused dog, and I asked the social worker if anything needed looking into. We agreed to defer any investigation until the psych team came by to see him, since he'd had no psych meds for days and is technically schizophrenic. Sure enough, he was having a massive onslaught of hateful and abusive voices telling him that he was a bad patient and deserved to die and that the people here were waiting for him to go to sleep so they could hurt him. Jesus motherfucker. We started him on orally-dissolving cheek-absorbed olanzapine to help him. It's really easy for things to slip through the cracks, but I could kick myself for not pushing sooner for other psych med vectors.

Meanwhile, I replaced my old bradycardia dude with a new guy from the cath lab, a fifty-year-old man with a history of morbid obesity, prior V-fib arrest, two cardiac stents, heart failure, diuretics and sodium restriction, diabetes, chronic renal insufficiency, and a pacemaker. He and his whole family reeked of cigarette smoke and not one of them weighed less than a Ford pickup. "Genetics," he said. "My bad luck. Dad had a bad heart too." I mean, no. It's not genetics. You might be a nice dude, but you're also fat as hell and it's literally killing you. Your blood is so sugary it's shredding your heart from inside out and your blood fats are so high that butter chunks the size of thimbles are bobbing in your aorta, and THAT, my friend, is why you're dying.

He had another stent placed, a 98% OM occlusion roto-rootered out. Lingering reperfusion pain. Nitroglycerin, morphine, and a nice neighborly dose of ativan fixed him right up. Still had the arterial sheath in his groin where they'd gone in, done up nice and neat with a syringe of heparin taped to it and the line clamped, presumably full of anticoagulant. Orders to remove it two hours after the last bit of anti-clotting agent went in. He complained nonstop about having to keep his leg straight, which I understand sucks, but also which I understand is LESS horrible than 10/10 crushing chest pain with blue-lipped shortness of breath. Maybe my priorities are fucked.

After that it was just putting out fires for a while, but sooo many fires. The next pt down the hall was receiving continuous renal replacement therapy, a sort of constant bedside low-grade dialysis that requires a one-to-one nurse who can constantly monitor and adjust it. Nobody else on the floor besides that nurse was checked off to handle CRRT, but I've done it at other facilities a million times, so the charge nurse asked if I could break the CRRT nurse for lunch. No big, done. Then gave another nurse a break-- I've had both of her pts before and knew them well enough to need very little report.

Stent guy wanted lunch, but declared that he hated hospital food. Family offered to go get him something to eat. "I want one of those bacon crab mac and cheese plates from Cheesecake Factory and an order of crispy egg rolls," he said.

"I'm so sorry," I cut in, "but both of those are definitely off the menu. Let's see if we can come up with something better for you."

"Why can't I eat what I want? I'm sick, I need comfort food."

"Sir, you just had a heart attack."

He looked at me like I had just started speaking Urdu. "...And?"

Family left with orders not to bring him ANYTHING and a very pointed hint that they might want to attend his meeting with the nutritionist tomorrow.

Pt ordered a burger from the hospital menu for dinner. Did not want light mayonnaise. Angry that the burger would not include cheese. Asked if he could have three burgers, hold all the veggies. Dietary declined and pointed out that this would put him far over his daily salt intake limit. Pt stewed for an hour, then called his mother and asked her to sneak him a cheesecake.

Darwin is coming for you, sir.

At this point, exhausted, I went into neuro guy's room to give him a tylenol (paracetamol) suppository, his IV antibiotic, and his IV metoprolol. The cheek-dissolving schizophrenia med was nowhere to be found; I messaged pharmacy to have it sent up. Everything was due at 1400, an hour before shift change for the eight-hour nurses (not me) at 1500, so there was a line for the drug machine. He was pooping in his bed, and his previous IV medication wasn't done yet, so I figured I would go take a lunch nap for thirty minutes and come back at 1445 to finish everything.

At 1440 the charge nurse woke me up and told me I would be taking the CRRT pt at 1500, checked off or no, because that nurse had to go home and there wasn't anyone else to cover. Fuuuuuuuuck. I went and gave report to the oncoming nurse, apologizing for the state of things, putting the cheek-dissolving medication from the tube station straight into her hand, and helping her clean and turn the guy (who had finished pooping). Then I dashed over and took the world's most intense report on the CRRT pt, who was preparing to have her CRRT run ended so that tomorrow she could have normal dialysis. CRRT is mostly the same wherever you go, but the charting varies a bit.

Oncoming nurse for my other pts comes into the room, raging. She is very upset that I left her so many chores to do. The room was messy, the meds weren't given on time, the orders weren't cleaned up, etc etc. I stare at her in bewilderment. Did I not tell her explicitly that I got ambushed with a pt exchange? I walked her through all of this, I know I did. I helped her clean up the guy. What is happening.

Oh. That sheath I was going to pull at 1500, the one that was heparin-filled to keep it from clotting? Oh, this facility (where I have been working for six months) doesn't use heparin. All its arterial sheaths have to be hooked up to pressure bags to keep them from clotting. I am utterly horrified-- turns out nothing clotted and he was fine-- and then humiliated beyond reason. The charge nurse comes into the room and asks if I have much experience with sheaths. (Basic sheath management is taught in nursing school and learned hands-on during the first week or two of any ICU career, since every ICU with a cath lab gets thirty of them a week.) I stare at my hands, face burning, and wait to die. 

I insist on writing up the incident report with the charge nurse. I kind of want to puke. The other nurse comes back every five minutes to tell me about another thing she found that I did wrong/didn't do/should have cleaned/should have told her in report. Some of the stuff is truly piddling. She's angry, but rightfully angry, because she got shafted. I also got shafted. I look out the window, where some kind of fluffy tree is shedding its down into the breeze, where it drifts lazily through the air over the highway and makes the world outside look hot and slow. The hospital seems to be immersed in golden brilliant syrup, an ocean of something too heavy to inhale. If I stepped out into it and held my breath, I would gradually ascend to the surface, a big human bubble rising through viscous light.

I shake myself out of it. Day six of seven is full of weird little moments like this. I am very tired and I want to breathe air that isn't filtered. The CRRT machine beeps and I empty its four-gallon bag of pee.

The pt has a drain tube in her abdomen that collects oozing, gloppy tan stuff as it pours from her abdomen, where her colon suffered two recent surgeries after a perforation. (The subsequent infection is why her kidneys are so fucked up.) I can't tell if it's pus or not and I'm a little worried. I page the GI physician's assistant, and am treated to an amazing story: apparently the colon, when shocked, forms a thick brown crust around itself called a rind, which later liquefies and oozes away. Since she's starting to recover, the rind is dissolving, and the halfway-open incision on her belly is giving it a place to drain to, mostly into the drain itself. The sixty mLs of tan phlegm I've been pouring out every hour are, apparently, liquefied traumatic colon rind. I know what I'm naming my next garage band.

I educate the pt's family extensively on renal health and infection processes. They all look tired and bruised. I bring them coffee and very gently ask the daughter to take her father home and have him get some sleep. He agrees to go, and kisses his wife's forehead goodbye. She squeeze his hand back, the first purposeful movement we've seen since she got sick. He cries hysterically and kisses her hand over and over. Their daughter guides him carefully out of the room to the waiting transport wheelchair that I've called to carry him to the car. I promise to call if anything changes, and he says he will be back in two hours. The daughter quietly tells me that if he falls asleep, she won't wake him up unless I call.

She really is getting better. I think she stands a chance.

There is a potluck in the break room. I manage a ten-minute break, load up on quinoa salad and lettuce salad and hummus, and quietly mourn the huge pancit feasts of my previous facility. Food's pretty good though. I cram it down, bitch a little about my day, get back to work. As i leave the break room a coworker comes in with a flan in a cake pan, which he dramatically inverts onto a plate. It's not a flan at all, it's a butthole-textured, donut-shaped jelly cushion used in surgery to keep pressure off patient's faces while they're lying face down. I laugh so hard I fart.

I give an uneventful report, change all the CRRT bags, and stagger to my car. My sister, who is in nursing school, has texted me: her friend from her rock-climbing days in Yosemite died yesterday in a failed base jump. I call her up and listen to her work through it as I drive home. She's a CNA when she's not in class, and she's calling me from the break room at work, crying. Ten minutes later somebody comes to get her because one of her pts has had a big bowel movement. I remind her that I'll see her at the end of the month and we say goodbye, neither of us admitting that today all our goodbyes feel a little like freefalls, because death and horror have become so familiar to us that we only notice them when they happen suddenly at the end of a plummeting drop.