Monday, July 20, 2015

Week 6 Shift 1

I called in on my day off to make sure Tiberius was doing all right. Pretty good, said his nurse for the day, still slowly tuning him up for a thoracotomy revision. He had another episode this morning, but he’s recovering all right.

Episode, I replied. What episodes? Did something happen?

Turns out, his left chest tube—the one draining his empty pleural space—clogged itself up the night before, and within about twenty minutes he was building up air in the space, which rushed in and had no way to escape. Slowly the pleural space was inflating itself like a balloon, crushing his heart and his other lung and pushing even his larynx off-center: another tension pneumothorax, one of the deadliest complications possible in his current state. The prickly doc made a quick desperate decision and stripped the tube, sucking the clot out into the drainage chamber and restoring the escape route for all that air.

In the short term, of course, she saved his life. There wasn’t any other option. In the long run, she gave the cardiothoracic surgeons a complete mental breakdown, because the suction created by the tube-stripping ripped his stump just a little more.

Which tells us a really awful thing about his prognosis. That bronchial stump is not doing well. It bleeds frequently; it leaks air occasionally; and with the slightest tug of pressure, it tears and leaks even more. For the flesh to be that friable, that ready to fall apart… it sounds an awful lot like lingering cancer.

The CT surgeons had already noted that they couldn’t get a clean margin on the tumor. His prognosis isn’t great even if he makes it through this immediate crisis. I should not be getting attached.

The afternoon of my day off, the pulm doc gathered together a team and exchanged his breathing tube for a longer one with two lumens (tubes). One lumen’s inflatable cuff put it right in the carina, the bronchial split; the other was placed by careful bronchoscopy in the right mainstem bronchus itself, isolating that lung from the stump so that they could finally, finally crank up his PEEP.

When I came in, however, his morning chest x-ray looked great from the nipple down and horrible on top. His right upper lobe had, apparently, collapsed. The pulm was called in again to retract the breathing tube from where the balloon cuff had slipped a little and completely occluded his right upper lobe. Then we cranked his PEEP way up for a while to pop it back open, and by the time this was done I finally crawled out for lunch and scarfed a freezer burrito before taking a short nap on the sofa.

My charge nurses and coworkers are a little weirded out by how easily I fall asleep on my breaks, and how soundly I snooze until my phone’s alarm clock goes off. I dunno, man. I think it’s understandable.

Back in the room, I found his wife alone for once, the rest of the family having gone for lunch. Despite the usual brightness in her voice, she looked exhausted and sad, and her expression as she held his swollen hand (puffy from the pressors, bound up with tape and tubing) was not one of hope. “It’s hard,” she said, “him not being here.”

And he wasn’t. Since we’d started sedating him deeply, he’d been gone: absent in presence, the center of the room and still conspicuously missing. For the first day or so, it had been a relief, to see him sleeping instead of grimacing in pain. Now, though, it started to sink in—Tiberius was somewhere else, leaving his wife to make decisions for him, leaving me to tend his body until he returns to it.

If he ever returns to it.

The shift stretched on: fine-tuning, occasionally stripping the chest tube in fear and trembling, turning him very carefully to avoid putting pressure on his remaining lung. I noticed that lying flat caused him to drop his pressures sometimes, and of course his vomiting continued—a mouthful of liquid green every time we turned him, often pouring out of his nose as well.

A little chart necromancy later, I realized he hadn’t had a bowel movement in… oh god, like a week. More than a week, despite all the bowel meds. He must be backed up to the collarbones. Which would explain the positional blood pressure—between the stuffed gut and the hiatal hernia, his heart was probably starting to feel the pressure. I talked to the doctor, gave him an enema, and started doubling down on his bowel meds.

At 1800 the charge nurse came up and asked me who I would choose to follow me on nights. The list was not confidence-inspiring. We have a lot of good nurses, and all of the nurses available were quite good, but few of them specialized in blindingly seat-of-the-pants critical pts like Tiberius and the few who did were earmarked for cardiac pts and an intra-aortic balloon pump. “Nobody else?” I asked, and the charge nurse winced.

“We’re incredibly short-staffed,” she said. “We’re just going to pair him with another pt and hope for the best.”

No fucking way. “I’m staying until 2300,” I said.

Sixteen-hour shifts are not fun. They aren’t a thing I like to do at all these days, and I won’t do more than one every couple of months. It’s too easy to fuck up your body—I’m 29 and I have gray hairs that all popped up at once after a six-month sprint of heavy shift work with multiple sixteeners per month. But they’re worthwhile in some circumstances, and this is one.

Still no bowel movement. I got an order for magnesium citrate, and carefully dripped it down his feeding tube, trying to avoid causing him to vomit.

The extra four hours passed much the same as the rest, but without any family members—they all went home to sleep. The room turned dark, and the unit started to really feel like night shift, my old stomping grounds (I went days in December). In the quiet, I nattered around the room, cleaning up and labeling lines and doing all the things that don’t fit during the hectic days, and which are a burden to the proper night shifters who come in after 2300 to a hospital with minimal support staff and pressure to keep all their work quiet.

I realized at some point that I was singing. I am not a singer—I actually have half a college degree in vocal music because I was a dumb kid at a bible college once, but I hate the sound of my voice and I only sing in the shower, or when I’m alone.

Alone, where nobody can hear me. Or where the only person who can hear me is too far gone to care. I was singing Rainbow Connection: have you been half asleep, and have you heard voices? I wasn’t doing a good job. Tiberius breathed softly under the coercion of the ventilator, not flickering an eyelash at my terrible singing, drifting on an opioid sea. I wonder what dreams he’s chasing, out there in the dark.

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