Saturday, July 11, 2015

Week 1 Shift 3 (7 of 7)

I slept until 0900 this morning, laid in bed playing Monument Valley on my phone until 1045 (I have legitimately not played this game at all despite all my friends telling me I would love it), then convinced myself that brunch and a shower sounded better than just lying in bed forever. The shower was amazing because it took place in the middle of the day with no time constraints and I could shave everything and spend plenty of time staring at the wall and thinking about absolutely nothing. Showers are usually ten minutes of scrubbing, shampooing, and telling myself aloud: "Come on, come on, you're okay." They usually take place at 0530. 

This shower went on so long that I made my husband bring me hot tea with milk and sugar, which I drank in the shower, setting it on the little shelf between sips. He stuck around and sat on the (closed, hopefully) toilet and told me about the airplanes he saw at the flight museum restoration hangar last week. We haven't seen much of each other this week, so while I care very little about airplanes, it's nice to hear him talk about things he likes.

Then I had a fucking decadent brunch before time for him to head to school. Now I am sitting in a nest of blankets and pillows on the sofa. The coffee table is arranged with the accoutrements of another couple of dumb hobbies of mine, different types of tea in several french presses and teapots + an honest to god thirteen jars of different kinds of honey. I had a weekend in Hawaii recently and bought YET ANOTHER sampler set of honey and I like to sit with my tea and my honey and a pile of chopsticks and compare the different flavors. If I had a shit-ton of different kinds of cheese this setup would be perfect. Hi, yes, I am the most boring person you have ever met.

The point of all this is: I will write up this report in extreme comfort.

Yesterday morning I took report on my CRRT pt, whose renal replacement therapy had been turned off overnight in preparation for the day's dialysis, and another pt who was preparing for discharge after having a cardiac stent placed. I made sure the first pt was comfortable and all her drips were stable-- she was still requiring a little bit of norepinephrine to keep her blood pressure up-- and then settled in to discharge the stent guy in record time. (Different stent guy from the previous shift. That dude was still checked in down the hallway, ringing his call bell constantly to ask if random tiny things meant he was dying. I answered a few of those calls while his nurse was busy, and reassured him that a random itch on his foot, a mild headache, and a restless feeling in his legs were not in fact signs of imminent death, though I was a bit more tactful about it.)

Taught the stent guy about his new blood-thinning medications and blood-pressure medications. He had a lazy eye that wandered around as I talked to him. Very difficult not to attempt normal eye-contact interactions with the lazy eye. Very polite and personable fellow, I just have a weird thing about lazy eyes that I have to compensate for so as to keep from being an asshole. Finished the discharge, pulled out his IV, and called the transporter to come wheel him down to his wife's car.

Caught up on my lady next door, whose blood pressure was kind of labile. Part of it was that I'd been measuring her BP mostly by an arterial line, which is a notoriously finicky process. I suspected she was also having breakthrough pain even under sedation. Turned up her fentanyl and crossed my fingers that I wouldn't bomb her pressure, and voila, she evened out. I don't blame her. The semi-open abdomen thing looks like hell. Her colon rind drainage was significantly reduced in volume and more liquid today. Her toes still look like shit-- she had very high doses of norepinephrine (also known as levophed) to keep her alive during the height of her illness, and norepi is well known for constricting your blood vessels until your toes turn black and drop off. Pt's family kept massaging the gross purple-black toes, trying to bring back circulation. Educated them on the importance of not dumping dead-tissue toxins into the bloodstream. Yes, she will probably lose most of her toes, although she stands a decent chance of living, so stop trying to milk rotten toe-meat back into her arteries, we cool?

Her toenails were solid lumps of fungus. Family was bare-handing that shit. I must just be squeamish from hospital work but I wanted to throw up just watching it.

Got caught up, oh my god, and went to help out down the hallway, where another nurse was landing a complete clusterfuck of a situation from the operating room. Her pt was an attractive lady in her fifties, wearing the kind of makeup you see on real estate agents, bleeding like a Tarantino extra from all her holes with her gut laid wide open under a delicate sheeting of saline-soaked gauze. Apparently she had been at work earlier and felt something 'pop'. Perforated small bowel, plus during surgery the MD had discovered a previously stable renal-aortic aneurysm which began to dissect under the stress. Deeply sedated and intubated, of course, but the room was a disaster area and the nurse was frantic. I called lab for her to make sure they'd started processing the pt's stat hematocrit, which they had not because uh, oops, then drew more labs, read blood, and generally did scut work for about half an hour until things started to calm down. 

One 'reads' blood by verifying all its information against the pt's armband, the computer's cross-checking sheet, and the various stickers on the bag of blood itself. Giving a pt the wrong blood can be swiftly and horribly fatal. Two RNs are always required for blood checks.

Bailed out of that room to attend rounds for my lady. Rounds involves an assortment of hospital professionals, the care team, who circulate through the ICU in the morning and check up on all the pts to make sure nothing is missed. The intensivist, pharmacist, nutritionist, charge nurse, physical therapist charge, respiratory technician charge, and occasionally others like the infection control specialist or the social worker all gather up with their rolling computer carts and surround you, and you give report and talk about any concerns or plans for the day.

Code blue by the front nurses station, yesterday's first heart-surgery pt. The pt's daughter came screaming and jumping out into the hallway, having pressed the code button herself. She was apparently an RN herself. The code team swarmed in and found that he wasn't dead dead, he was just having a massive vagal response from bearing down hard on the shitter while his heart was still stiff and shocky after surgery. Sigh of relief all around-- he wasn't an open-heart valve repair, just a triple bypass, so he didn't have pacer wires still installed (we keep them in the valve pts for a long time because valve surgery often disrupts the nerve pathway through the heart, resulting in sudden drop-dead moments like that one guy the other day) and therefore wouldn't have been an easy fix (seriously, nothing is easier than bringing back a valve pt with a pacemaker). 

The housekeeper came by to stat clean the now-empty room where the stent guy was before. Why a stat clean, I asked her? Oh, she said, you're getting a patient in this room. Me specifically? That's what the charge nurse said. WHAT THE FUCK. I call the charge nurse and ask if this is true, and sure enough, I am getting a femoral-popliteal bypass case from the OR in about thirty minutes. Oh, I didn't tell you? I'm sorry.

The lack of communication is killing me. Toward the beginning of this run of days I was caring for three telemetry-level pts (a step down from ICU critical care), preparing one for a routine cardioversion, which for tele pts involves the team carrying them down to Special Procedures and bringing them back when they're finished. Instead, the whole team showed up at the bedside and asked me where the paralytics were. Turns out, somebody had decided to intubate the pt, perform a trans-esophageal echocardiogram (heart ultrasound from inside the esophagus), and cardiovert (shock the heart to break the pt out of a dangerously fast rhythm) AT THE BEDSIDE. Assurances that the pt would be made critical-care status. I ended up demanding that the flex RN take over that pt one-to-one, and I'm glad I did, because she turned out to be an utter disaster and there was nobody to take my other two teles.

And after the previous shift's CRRT ambush, I really was not feeling good about the communication level with that charge nurse.

Turns out though that she was just trying to make sure I got the easier of the two incoming pts, and had been delayed in telling me because the RN getting the other pt needed a lot of help setting up. Not excused, but understandable. 

Elevator call: my pt was on his way up. Out of nowhere, code blue. A pt on the other end of the unit who had been on a balloon pump-- a sausage-shaped balloon in his aorta that helped pump blood with each heartbeat, really cool tech but very risky-- had gone into cardiac arrest. The whole unit poured into that room to bring the guy back to life, leaving me to admit the new guy alone. This sounds worse than it is, mainly because the new guy was super nice and his wife was super nice and everything had gone without a hiccup. His potassium was very high, because his kidneys were chronically insufficient and he couldn't shed potassium very well, so I gave him a medicine to drink that gives you insane diarrhea but dumps all your potassium through your butthole. He was not happy about this, but he understood. We looked up all of his meds together and made sure everything else was right. 

He kept asking to pee, but he had a foley catheter in-- a tube that goes up your dick into your bladder to drain it. I kept telling him to pee whenever he needed to, but honestly, foleys are uncomfortable as shit. His leg looked great where the closed-off arteries had been bypassed and his pulses were strong. The incisions were minimal. I told him he'd be bikini-ready in six weeks and he laughed and spilled his cranberry juice everywhere.

The balloon pump pt survived, but was for some reason immediately moved into full airborne precautions, the kind we use for tuberculosis. I still have no idea what that was about, but the nurses involved in that disaster were totally isolated for the rest of the shift, wearing bubble helmet respirators and gowns in an airlocked room at the end of the unit. I can't even imagine taking care of a fucking balloon pump pt while under full airborne precautions. I am a sucker for high-acuity pts but that just sounds exhausting.

Dialysis nurse showed up in the next room. I love it when my pts go on dialysis because they get a dedicated nurse to run the machine, which means I don't have to watch as closely because somebody with at least half a brain will let me know if anything's changing. Sure enough, as soon as he hooked her up, her blood pressure on the arterial line dumped. We both panicked a little and tried a few things, but nothing was touching that shitty blood pressure. I noted that the dialysis catheter was accessed on the same side as the brachial art line, suspected that the arterial outflow through the HD cath was sucking pressure away from the art line, and put a BP cuff on her other arm. Sure enough, her BP was fine. Maybe a little on the high side. Fuck yes, dialysis go.

Helped a nurse the next room over with bathing and prettying up her pt. I have taken care of this pt frequently over the month she's been on our ICU. She's in her thirties, a mother of two and part-time special-needs tutor, with a sweet-faced husband at her bedside constantly. She was very healthy before this, got strep pneumonia that turned into necrotizing pneumonia, had half her right lung cut out, held a fever of 38.9C+ for two weeks, coded twice, nearly died more times than I care to count, swelled up into a water balloon, lost all the water and is now sunken and sallow, now has a tracheostomy and a chest tube, and has generally been so much work to keep alive that we rotate on and off so nobody gets completely worn out on her. She's been better this week, though. Her husband didn't want to bring her kids in while she was super sick, for obvious reasons, and they're like two and five anyway so it's not entirely safe to have them on the ICU.

This was her older child's sixth birthday, so we arranged a surprise for her. Her husband went home "for the afternoon" like usual, to pick up the kids, and her nurse and I washed her hair and generally made her presentable and even pretty while the charge nurse ordered cupcakes from a nearby bakery (with extras for staff because fuck yeah, petty cash). We sat her up in the chair and she was watching a little TV when her husband returned with a pile of presents, a slice of birthday cake, and her now-six-year-old son wearing a paper crown. He started screaming as soon as we let him in the room, and she cried and managed to hold her arms up long enough to hug him. The whole fucking unit's worth of staff was gathered around that room, let me tell you.

The kid showed her his new spiderman doll and his books, opened a couple of presents and discovered a spiderman backpack and a candy bar, jumped around the room with delight, and could NOT stop telling his mother everything that had happened that week at school. After a while her crying started to really confuse him, and he asked: "Why are you sad?" Climbed into her lap (nurse at hand to keep the chest tube from getting kicked) and started fucking wiping the tears off her face. Then he started crying too, wiped his own face, and announced in bafflement: "I'm not sad!"

Look, we don't get a lot of great stories like this on the ICU. Most people die, or have long slow shitty recoveries, or are 107 and should have died anyway, or are just here for a quick cardiac stent and go home the next day without realizing they totally clipped Death's elbow in the cath lab elevator. We are all cynical assholes who don't get our hopes up. Most of us hate children. This shit made every last one of us cry like morons. Fuck. Moving on.

She's supposed to go to rehab next week after the chest tube comes out. Prognosis is pretty good at this point. 

Back to the lady on dialysis. I did her dressing change, packing saline-soaked gauze into the open places on her belly and covering it with dry dressings. The colon-rind liquid coming out of her drain was starting to clear up a bit, and had the texture of hot sauce rather than ketchup. Her left arm, where the blood pressure cuff was squeezing her forearm below her PICC line, was incredibly swollen, like the whole thing from fingertips to shoulder. Oh god, she's totally getting a DVT.

PICC lines, because they're long IV lines that follow an entire vein back to the heart, are prone to gathering clots around them. A big clot in a large deep vein-- a Deep Vein Thrombosis-- can be a major issue. I took off the cuff and helped the dialysis nurse lock and pack her dialysis catheter-- she was done with the run and had tolerated it well-- and prepared the room for report to the next nurse. I realized I couldn't remember whether the opthamologist came by today; she was supposed to get her eyes checked to make sure that her fixed upward stare isn't a sign of nerve damage, like a yeast-clot stroke behind the eyes. All in all, though, I felt pretty good about the day; my fem-pop guy was having great pain control and excellent pulses and a nap after dinner, my HD lady was down 3.5 liters of fluid and a bunch of toxins and will start losing some of her swelling soon (hopefully), the lady next door was wrapping up the world's most tearjerky birthday party, and the open-gut lady down the hall was starting to pull out of her tailspin.

I left the hospital about thirty minutes late, had home-cooked dinner with my friends and their disastrously cute 2.5yo kid, listened to podcasts about birdcalls because one of them is really into podcasts (fuckin nerd lol), and don't really remember how I got home.

5 comments:

  1. Have you ever tried Leatherwood honey? If not you should try to get some, it's Tasmanian if that's any help. It's pretty unique - I've personally tried a lot of honey and haven't yet found anything quite like it, so it'd be pretty neat to find out what else is out there with that same twang. I love the stuff. Also love this blog, RPA (australian tv doco follows patients in a hospital) is one of my fav shows.

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    1. Leatherwood? I am definitely gonna hunt it up... the twangiest stuff I've tasted so far is German Forest Honey, which is downright funky. Might have to look up RPA too... I loved Scrubs just because it was the only vaguely accurate look at hospital life I'd ever seen on television.

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  2. Can someone direct me to a good place online to buy samples of honey? I like it in tea and drizzled on bread but I live out in the boonies so it's hard to find the more exotic varieties.
    Loving the blog as well BTW.

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    1. Good question... I don't know about samples, but I know that if you look for local honey from certain areas, you can often find samplers of different types. Mostly I cruise Amazon, exchange honey with pen pals and friends across the world, and keep my friends scared of the consequences if they fail to buy me honey when they see it.

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    2. I put mine in the microwave so then it will drizzle. Be sure to remove any metal lids. Glass containers are obviously better for this than the plastic :X

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