Monday, July 20, 2015

Week 5 Shift 2

Day two of the pneumonectomy pt’s care. Day two, also, of the crazy Farsi family and their merciless caregiving.

I’m afraid the crazy family didn’t get as much attention as they probably could have used today. Specifically, I didn’t have time to do all the boundary-setting and therapeutic communication I would normally expend on a family that challenging. And their level of challenging increased throughout the day.

Early in the day they remembered that some nurse had told them once that their grandfather’s tube feeding should be paused whenever he’s being repositioned, to keep him from throwing up tube feeds. Research doesn’t support this, by the way; a lot of old-school nurses still prefer to pause while repositioning, but the fact is, the 10mL of fluid your pt will get while lying down and turning will have almost no impact compared to the residual that’s already sitting in his belly. And, in fact, I don’t ever pause tube feeds when I have a pt on both tube feeds and an insulin drip, as he was.

This is because an insulin drip carries on dosing the pt whether your tube feeds are running or not, and pausing the insulin drip while the tube feeds are on hold does not guarantee a proportional sugar/insulin level when you resume. And it’s very easy to hold the tube feeds and forget they’re turned off, unless you use the two-minute pause, in which case every two minutes it shrieks in your ear like a demon tunneling into your cerebellum… which, in turn, means you slap at the TF pump with your shit-smeared glove fingers until it stops beeping, and you stand a decent chance of turning it off entirely, which prevents it from reminding you if you leave it off for thirty minutes.

And if you turn off your TFs for thirty minutes while your pt gets 15 units of insulin intravenously, you will come back to a pt with a blood glucose of 12 and intractable hypoglycemic seizures. Fortunately, the first and second and third times the family stopped his tube feeds so they could reposition his legs twenty millimeters to the left and then forgot they were turned off, I checked on him before his glucose could drop too far.

This was bad enough, and I had to threaten to remove them from his room entirely for his safety. But midafternoon I returned to the room to find all his IV pumps turned off, including his amiodarone (an antiarrhythmic we were using to control his rapid atrial fibrillation), and blood backed up his central line halfway to the IV pump because there was no positive pressure to keep it from leaking.

I lost my shit. I threatened to have them removed by the police for attempted murder. I told them that if they touched his IV drips again and he died, they would all go to jail. I told them that if they stopped his tube feeds and he went into seizures and a coma, I would make them all stay in the room while he seized and likely died, and they could all know it was their fault.

I don’t often go off that way. But every one of them was an adult, every one of them had been warned numerous times, and every damn one of them has been caught red-handed fucking with something in the pt’s room in a way that could seriously hurt him.

I went out to the nurse’s station and fired them. I agreed to keep them for the rest of the day, which is saying something given the insane acuity of the pneumonectomy guy, but I made it clear that I would not accept another assignment with that family. They genuinely got my goat. I am a little bit ashamed.

When I returned to the room, forcing a neutral expression and a positive attitude, I found that they had pulled the sterile dressing off his central line and were scrubbing the site with a washcloth they had, presumably, rinsed in the sink. I felt something go phut inside my brain and I said through gritted teeth: “I need you all to leave the room for a bit while I take care of a sterile dressing change.”

And after replacing his sterile dressing, I just called the flex nurse to perform all his care. There were only three hours left in the shift, I was busy, and if I had to listen to them argue about who loved granddaddy the most while simultaneously trying to kill him, I was going to spontaneously combust.

It wasn’t like I had nothing else to do. Pneumonectomy guy, hereafter referred to as Tiberius, started out the morning looking tentative and just went south from there. By 0830 he was having increased respiratory distress, along with bronchospastic wheezes in his lung and, to my horror, hollow rushing breath sounds in the empty space where his left lung was removed. A chest xray revealed a huge air pocket in the left pleural space—his left mainstem bronchus was leaking. I explained this to him and his wife, carefully, and he made a gesture with his left hand: poof, fingers splayed. Then he grimaced and lolled out his tongue and exaggeratedly rolled up his eyes.

“Well, it’s not good,” I replied. “But we can’t tell yet whether it’s blown or just leaky. So you might not die just yet.”

He acknowledged this with a wry twist of his mouth. This is not the first time he’s been handed a really nasty diagnosis. (It wasn’t non-Hodgkins, by the way; there was no effective treatment for that in the 80s. It was Hodgkins—thus the splenectomy and sternal radiation.) 

Today was his birthday.

The cardiothoracic surgeon who had done the original pneumonectomy was on vacation. The Trekker cardiothoracic surgeon who did that heart I took the other day was covering for him. He and his PA, a tall thoughtful-looking stepladder of a man I will call Pilgrim (because, if I’m gonna be writing this for a while, I will need nicknames for some doctors), made eyebrows at the xray film while I hunted up the pulmonologist. 

We have a pretty broad spectrum of pulmonologist and intensivist personalities on this unit: a new mother who goes by a disarming nickname, Sunny*, and will show up when you page her but very strongly suggests that you not waste her time; a prickly but brilliant woman who dislikes me (largely because I couldn’t figure out the paging system for the first month I worked there and paged her 2034832098432 times by accident); a worldly and fun-loving hedonist who gets very focused on one pt at a time and doesn’t like to be interrupted, but handles the highest acuity pts with TV-ready aplomb; a crusty, snappish fellow with eternal under-eye bruises who gets the job done in record time and has razor-sharp skills but occasionally has to be sauced back into respectful discourse; a slightly scattered gentleman whose hands-on skills are often tenuous but who can spot a trend or a rare disorder with incredible accuracy and whose hunches are always bang-on; a tall genuine fellow with immaculate button-down shirts who is gracious under pressure and never sweats; a terrifyingly competent and unstoppable woman who I could pick up and throw at least five feet except that I think she’s a black belt; and the thin, energetic head of the department, who manages to make everyone feel personally listened to and privileged to be held to his high standards. 

And then there’s this guy. This pulm is tall, grave, soft-spoken, relatively new, a recovering Catholic, and… well. As he examined the film, nodding and creasing his brow, the CT guys awaited his advice with bated breath.

“I’m gonna need an old priest and a young priest,” he said at last, and swooped away to examine the pt before we realized we were gonna have to laugh at that one.

That’s his deal. He delivers sterling one-liners and then leaves. I have never seen a single joke of his fall flat and I have never seen him stick around for the payoff of any of them. He is basically my comic hero.

He spent all of thirty seconds bronching the pt, which was a relief since Tiberius’s poor sedation meant he was desperately uncomfortable the entire time and squeezed my hand until the knuckles cracked, then announced that his left mainstem stump had definitely developed a fistula and they would need to perform a thoracotomy immediately.

“Maybe we should manage it medically until he’s more stable,” suggested Pilgrim, and the pulm shook his head.

“You have two choices,” he said. “You can take him to the OR, or you can take him out behind the woodshed.” Then he swooped away. Fuck that guy. I felt awful for laughing at that as hard as I did.

So they packed him up and took him down. His trachea was already beginning to push over to the side, as his empty lung pocket collected air that couldn’t escape and crushed his remaining lung (this is called a tension pneumothorax and is Bad). I made his wife give him a kiss before he left: for luck, I said, but I wasn’t sure if he’d make it back alive, and if my husband were maybe going to die I would want to have kissed him first. Thirty minutes later, just long enough for induction, I heard the overhead pager: the prickly pulm was being summoned to the OR. The OR where Tiberius was currently anesthetized upon the table like the evening in the poem.

This boded ill. This pulm is noted for her steady-handed bedside code work and management of nightmarish near-death situations. For them to page her instead of Dr Swooper... I sat at my workstation, charting furiously, knowing I was unlikely to get another chance for the rest of the day, and performed the first intervention on the crazy family’s TFs. 

Tiberius returned to me looking like death warmed over: ice pale, pupils wide open, with a shitty hematocrit (blood level) and a blood pressure in the seventies. He had two new chest tubes, a new arterial line in his left wrist, his feeding tube pulled out, and a huge fucking incision across his left side and back that made him look like the loser in a machete fight. The incision bulged and sucked in with each breath; Dr Trekker had not had time to close it properly, and had just stapled the skin together.

What happened was this: they put him on the table, right side down, and cut him open. As Dr Trekker opened his chest, a huge clot rolled out of his left mainstem bronchus stump and fell into his right mainstem bronchus, where it completely obscured all airflow to his one remaining lung. The prickly pulm spent thirty minutes bronching it out, during which his blood oxygen levels dropped to around 30% for two minutes, then 50% for ten minutes, before recovering to the 80%s. 

The bronchopleural fistula in the left stump was not repaired. Closure and placement of chest tubes had been emergent, leaving him with whatever chest tubes they had lying around—a pair of narrow, easily kinked tubes rather than the big hard tough ones we would normally use.

The family was glad to see him back alive. His wife cried and kissed him again. He just lay there, blank-faced, a waxy parody of the guy who had managed to write “WHO FARTED” on a clipboard from under full sedation the day before. The staff in the room met each others’ eyes, not the family’s. We have all seen hypoxic brain injuries.

“It could just be leftover anesthesia,” I said to the respiratory technician in the hallway. “He wasn’t down for long. He’ll probably come up soon.”

But he still struggled. Two units of blood later, we started levophed to maintain his blood pressure, and his hands and feet started to swell as the blood vessels in them became too tight to carry fluid back out of them. His blood pressure hovered somewhere between ‘tanked’ and ‘crumped’, which are the words that all ICU nurses seem to have spontaneously and simultaneously accepted as gifts from the ether to describe a pt that is diving into the homeostatic abyss.

And not a single response to anything we did. He stared blankly at the ceiling. I wanted to throw up.

Finally we all agreed: he just wasn’t improving. Air bubbles poured through his left chest tube in a continuous stream. His right lung had diminished breath sounds, and what air was moving sloshed through his semi-collapsed air sacs like shoes in a washing machine. It was time for yet another bronch.

Dr Swooper performed this one, attempting to advance the endotracheal tube into his right mainstem bronchus so that we could apply greater PEEP without totally blowing the stump. As he suited up, I ushered family out of the room and laid the pt flat so the doc could get to his breathing tube easily.

“Tiberius,” I said, more out of habit than anything—you don’t do anything to a pt without telling them first. “We’re gonna do another bronchoscopy, like the one we did yesterday, and see if we can get your breathing tube down a little farther.”

His eyes shifted and he looked at me. Unfocused, but he looked at me.

“It won’t take long,” I added, squeezing his hand, delighted to see his response. 

He locked eyes with me, a proper focused gaze, and then rolled his eyes at me in a big sloppy expression: yeah, sure, won’t take long at all. Tiberius was back.

The bronch wasn’t super successful, but we did manage to get it angled partially into the right mainstem. No PEEP, but protection from rolling clots. After that the GI doc returned and put another feeding tube down, and I held his hand during that and dosed him with huge boluses of pain medication until he was completely gorked again.

At this point I didn’t care to keep him awake. Anybody who can muster a sense of humor like that is gonna be just fine.

I passed off report and then dropped in to check on abd guy. He is not having a good time—his pancreatitis has progressed from necrotizing to hemorrhaging, and he’s taking a lot of blood, not really responding to much. They’re considering moving to CRRT instead of dialysis. His guts are all inside, but not making any noise, and the GI surgeon took him down and washed him out and couldn’t find any obvious problems besides ‘damn, this guy looks raw in there’. Still keeping an ear out for him.

I accidentally called Crowbarrens “Crowbarrens” to my manager instead of using his real name. I got the most confused look, and had to explain that I uhhhhhh made up a name to call him so I could complain to my husband about him without violating HIPAA. I am not out to my bosses about writing shift reports. I don’t think I’m doing anything illegal or unethical—I really am changing significant details—but bosses tend to be a little paranoid about things like that.

Tomorrow I’m going to insist on having him 1:1. He’s sick enough. He’s not appropriate to pair. I want to give him a lot more attention than I can drag away from another pt, and it wouldn’t be fair to the other pt anyway.

I know he’s not likely to live. I should really not be getting this invested.

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