Monday, July 20, 2015

Week 5 Shift 3

Day three with Tiberius. I showed up at work a little early, caught up with the night nurse, then headed to the charge nurse station and insisted that he MUST be made 1:1. They asked if I could take a telemetry overflow admit on the side, and I gently but firmly reminded them that I regularly balance absolutely unreal workloads and am very good at handling high-acuity spreads, and that the last time I insisted on a 1:1 the guy ended up with an open abdomen that afternoon. I got Tiberius 1:1.

Which is a good thing. His sedation was cranked way the hell up, which was appropriate-- even his breathing impulse was completely knocked out on 250mcg of fentanyl per hour + precedex at an obscenely high dosage (got an MD order to double the hourly dosage if necessary, rounded out about 150% of the normal max). And yet he was still waking up from time to time, glaring rings of white around his irises, the expression of puzzled horror that comes with sudden sharp agony. I've had my share of dental work done-- consequences of growing up without owning a toothbrush-- and I recognize the expression well enough, although I'm sure nothing that's happened to my mouth even comes close to the torture of two chest tubes, a partially-closed thoracotomy, a pneumonectomy, and multiple bronchoscopies per day. I dosed him with fentanyl until his blood pressure bombed, and his pressure was still labile for the rest of the morning, dumping whenever he dozed off and soaring whenever he awakened to stabbing pain.

The intensivists had switched out; Dr Sunny was covering him today, and I pitched my case for a new sedative. Given that he was still periodically vomiting, even though we weren't giving him anything by mouth/feeding tube except for a few ground-up pills every day, I was slinging antiemetics at him left and right, and the night nurse had reported a significant prolongation of the QT interval-- the time it takes for the heart to recover from each beat. (The risk being that his heart would try to start the next beat before his ventricles were fully recovered, which could cause his ventricles to freak out and fibrillate, a deadly arrhythmia.) I did some crazy ECG analysis and research and determined that his T wave-- the marker of repolarization, or post-beat recovery-- wasn't prolonged, but he did have a U wave, which is not uncommon for a pt on amiodarone (an antiarrhythmic we were giving him to control atrial fibrillation). The U wave is an extra little bump after the big T bump (after the jagged QRS complex), and apparently it represents the post-beat recovery of the papillary muscles, the little muscle-fingers that anchor and pull your heartstrings to stabilize and open your heart valves. The night nurse had measured from the beginning of the QRS to the end of the U, which made for an incredibly prolonged QT interval, but after a little fishing around on the internet (hey, we google stuff all the time on the ICU!) I found that most cardiologists recommend a slightly different approach.

You measure from the beginning of Q to the end of U only if the U wave is conjoined to the T wave, obscuring the end of the T. If the line returns to its baseline before the U starts, you only measure to the end of the T. Measured this way, he had a perfectly normal QT interval, and I was able to hand Dr Sunny a spittle-flecked piece of paper covered in deranged scribbling and caliper scratch marks and walk away five minutes later with an order for propofol.

It worked beautifully. Thirty mcg/hr of propofol later and Tiberius was sleeping like a baby. 

His wife, Amanda*, was finally joined by a bunch of family from around the country. They have a pretty large family, with various health issues and other things delaying their travels, but the trickling-in of relatives became a steady influx. They are a delightful family, some of them members of a very conservative religion, but free with their affection and bright in their humor and generous with their love. I am not a religious person-- I have some deep and intense spiritual drives that are still bleeding where they were severed, and I still dream of something more satisfyingly divine than the mannequin-god behind the curtain of my milk-faith, but I also have some major bones to pick with organized religion-- but if I had to live in a church faith, I would want one that let me laugh and gossip and cry with my husband's sister and her wife, one that made his grandmother's travel-induced diarrhea an affectionate family joke instead of an unclean shame, one that gave me stories and hope and peace with either life or death, whatever pain or loss followed in its wake.

Good people. Dear people. I wish I could give them the miracle they're hoping for.

While all this was happening, there was a code blue in the ER, followed by a rapid transfer of the pt to the room two doors down, where the horrible family had been before. (They were moved last night because the workstation-computer-cart caught on fire, shortly after which the grandfather had another hypoglycemic episode because the family paused his tube feeds again while they were trying to turn him WHILE THE STAFF WERE TRYING TO EVACUATE THEM FROM THE ROOM. Security was called and the family was limited to one member in the room at a time, with a warning that whichever of them was present next time he had an episode would be banned from hospital grounds.)

This new pt was an older man with a medical-condition necklace on: heart failure, diabetes, etc. It didn't matter much to me, since I didn't get report on him and didn't have any part in his actual care. Except that, ten minutes after arrival, he coded again, and because I was close by I jumped in to help. There wasn't much to do, as everyone else had their hands on the code stations: med nurse, push nurse, chart nurse, resp therapist, and shock nurse. However, from the door I could see that the two-man rotation on chest compressions was having a hard time, mostly because the pt had nothing hard under his back and had to be compressed deeply into the bed to get enough smash to move his ventricles. So I dove in, spiderwebbed through the lines and tubes to the head of the bed, ripped off the CPR board, and shoved it under him at the next compression switch, put the bed on max inflate for a harder surface, and jumped in at the next round to be the third man in the compression chain. Three is a good number; otherwise your arms get really tired.

I am relatively new at this facility, and we are pretty good at preventing codes, which means that I haven't been in a full-bore code in a major role yet. I've carried flushes and even pushed meds, but codes are fast and wild and require strong communication, which means that I'm still at the stage where chest compressions are an appropriate role for me to fill-- a role I share with CNAs and even housekeeping staff in a pinch. I don't mind-- compressions are a workout, and good compressions can make all the difference.

However, this dude was completely fucked. Flash pulmonary edema filled his breathing tube with bubbling red at every compression. His heart wobbled through ventricular fibrillation with the kind of half-assed exhaustion that doesn't respond to shocks. Med after med failed to get a response; shocks and compressions were like rocks thrown down a well. In the hall, his family wailed and collapsed against the wall, and shouted for us to save him. A nurse from down the hall gently guarded the door to keep the more frantic family members from seeing the bloody wreck of a corpse that we were preparing to stop beating.

We called it after twenty minutes. His chest was the texture of new banana pudding, before the cookies have a chance to get soggy-- bone fragments scraping the sternum, muscle and fiber pounded to a pulp. 

CPR is violent. It's effective enough to give us a chance to perform life-saving interventions, but if the meds and shocks don't work... well. Eventually it just becomes mutilation of the dead, the hidden ritual of American healthcare, the sacrament of brutality by which we commit our beloved to their resented rest.

The family burst into the room, still screaming, still demanding that we bring him back. "Keep going," they said, "he's strong, he'll be fine."

The RT popped the ambu bag off his breathing tube, and blood flecked my left elbow where I stood, wringing the numbness from my fingers over his demolished chest. Someone had thrown a pillowcase over his genitals. His skin was the mottled color and temperature of cheap cotto salami. "Wake him up," his son shouted at me from the door.

Instead I leaned over him and closed his eyes. "I'm so sorry," I said. I don't think his son heard me over the post-code chatter in the room, but he fell silent and white. There's a finality to that gesture that speaks more to our sense of gone, lost, dead than any words or blood or broken bones. They retreated into the hallway and sobbed there until the chaplain ushered them away to a private room. I scrubbed my bloody elbow in the sink and slipped out among the other staff, back to Tiberius, back to smile and offer support to Amanda while she and her family told stories about his childhood.

That disconnect is like a ringing in the ears. Death is touch and go: it touches you, and you go. If you're the lucky asshole in scrubs, you go into a different room, and think about it later. If you're the unlucky asshole in the gown, you go where we all go, eventually.

Anyway, after that I insulted the living hell of out an RT by accident, calling her a "respiratory technician" instead of a "respiratory therapist." I actually am shit at terminology like that sometimes and I felt terrible, but I think she understood my ignorance. Any RTs reading this probably just bared their teeth at me a little. Sorry, dudes, I couldn't do a quarter of my job without you. My apologies for fucking with your fiO2.

After that, I spent the evening fine-tuning Tiberius. He needs another surgery, a repeat thoracotomy to finish closing the stump and properly close his back, which looks like fucking hell. Before we can do that, we need every possible advantage to keep him alive, which means crazy tuning up and blood pressure management and cardiac output optimization. I can't describe to you how boring this process is, or how riveting. It's a game; manipulating numbers, one up one down, tightening your margins and leaving wiggle room; it's also a slog, poking this button and that button and making puckered mouths at the monitor while you try to decide whether this is a fluke or a trend. Overall, though, he trended upward. 

By the time night shift arrived, I was beyond exhausted, and worried sick because I knew I would have a day off tomorrow. I wrote up an extensive report sheet on him to be handed off to night shift, complete with goals, responses to titration on each drip, and precipitating events associated with each previous destabilization. I think the night nurse was a little insulted when I handed it to her, until she started looking over it and asking questions. By the time I left she was making a few addenda of her own to the list, and running off copies. I wished her good luck and godspeed, said goodbye to Amanda, and staggered to the breakroom to clock out and take a fifteen-minute nap before trying to drive home.

I called in the next day and asked how he was doing. Fine, they said. Stable and gaining. Still in ARDS, still on pressors, still requiring extensive sedation, but still alive.

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