Sunday, July 12, 2015

Week 2 Shift 1

By the time I clocked in yesterday morning, the fem-pop guy had been transferred to a telemetry unit in preparation to have him go home later in the day, the neurodegenerative guy had been sent home on hospice (probably won't die immediately, but will be allowed to drink water instead of begging for swabs), and the intensivist was standing at the front station talking about Rachel*, the birthday mom, and her swallow study later that day. They planned to try her out on a Passy-Muir valve, a type of tracheostomy apparatus that allows the pt to push a button so that they can speak and eat. 

I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.

Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late. 

Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.

He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.

A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy. 

Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.

It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.

I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak. 

Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.

It's just much easier to package this as a superstition.

I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.

After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery. 

They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.

This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.

And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.

But that's just, like, my opinion, man.

My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.

Wait until they find out how I feel about the Silmarillion.

PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.

HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:

--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.

It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid. 

She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.

She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.

We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.

Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.

The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.

I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.

By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.

Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.

Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.

I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.

The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.

I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.

Now I'm going to have a nap.

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