I walked onto the unit and was greeted with perplexed stares. “What are you doing here,” said the charge nurse, frozen in place, still holding her pager six inches from the countertop where she was reaching. Everyone who wasn’t already giving me a funny look turned and joined the crowd.
“Uh,” I said. I hadn’t had any coffee yet. “I work here?”
“You aren’t scheduled today,” said the charge nurse. “The book says you’re on vacation.”
I considered this for way, way longer than I should have. I was leaving
the next morning at the crack of dawn, headed out to the Olympic
Peninsula for a weekend of camping with my husband, one of my closest
friends (whose wife, my other closest friend, was stuck in town for the
weekend with houseguests), and my friends’ ridiculously adorable kid,
the 2.5yo. I hadn’t packed yet, had done minimal food prep, and hadn’t
slept worth shit for a week because I was worried about Tiberius.
“So… should I go home?”
“No no no no! Don’t go anywhere! Can you stay? You’ll get your pt back. Don’t go anywhere.”
Just then my unit manager arrived. “What’s all the shouting about,” he
said, then spotted me and pulled a double take. “I thought you were
“That’s tomorrow,” I said. “If I stay until three, can I go home?”
So I ended up working a measly eight hours today, which was a blessed
relief, because Tiberius was gearing up for a Hail Mary surgery first
thing tomorrow morning and needed every delicate fine-tuning touch I
could give him. The pulms and CT surgeons agreed: the repeated chest
tube occlusions and stump perforations were taking far too much of a
toll on his limited resources, and the still-sort-of-open thoracotomy
was starting to dehisce. The ARDS is beginning to retreat, but he’s
still hanging on the edge, and his cardiac output is consistently in the
trash because of the insane pressure differential in the various parts
of his chest.
My job today was to give him every inch of gained ground I could fight
for. I titrated down his pressors with extreme care, just low enough to
give wiggle room in case they had to crank ‘em up in surgery, not low
enough to challenge him. I talked plans with the pulm, and got orders
for albumin (to pull water in from the tissues) and Lasix (to shed the
water, reducing the heart’s afterload, the amount of back-pressure it’s
pushing against as it tries to perfuse the tissues). I timed them with
exquisite care and pulled this stunt three times in a row without
rocking his vital signs, before finally chickening out of Round 4
because his heart rate went up ten points.
And I started working really hard on his bowels.
Tiberius was backed up as all hell. I think I mentioned before that his
distended colon was causing pressure issues with his heart and his
venous return; I took it on myself to get that shit out of there, and
championed the cause of poop until I’m pretty sure Dr Sunny worried
about my sanity. I dosed him with bowel meds; I administered enemas; I
finally, in a fit of desperation, gloved up to the wrists and performed
digital disimpaction and stimulation of his rectum.
This is, if anything, less fun than it sounds. You basically glove up,
slather your fingers with lube, and work them up the pt’s back end until
you encounter stool. Scoop what you can, work anything loose that you
can, and stretch out the rectal muscle to stimulate the body’s “rectum
full, evict tenants” impulses. Tiberius couldn’t be turned on his side
for this, so I had to hoist up the boys, so to speak, and jam my hand
back in there from the front side.
As I got to work, I felt floppy skin lap over my wrist, local anatomy
returning to its accustomed position. Well, it’s not the first time
someone’s balls have posed me an inconvenient barrier to their ass. This
job can be undignified. I just didn’t look—this procedure is all about
proprioception and sense of touch.
I got a handful on my first fishing trip. A little dig stim, and his
rectum refilled; I pulled out pebbles and chunks and lumps shaped like
knucklebones and tiny flecks of shit-granite the size of rice krispy
cereal. My shoulders cramped up and my wrist was on fire by the time I
took a break; at my side, the bucket I’d allotted for captured items
contained a good double fistful of rock-hard desiccated shit.
An hour later I went digging again. This time I got pebbles with a little slushy liquid. Things were breaking free.
An hour after that I got nothing with the finger sweep, but during the
dig stim portion he started having a tremendous bowel movement. I’m
talking liters of liquid shit. It flowed and poured and could not be
contained, and with each surge of excrement, his blood pressure rose and
his heart rate fell.
All told, I think he shit about a gallon, roughly four liters. Enough
that I was able to turn him when it was time to clean him. Enough that
his family, who have a high tolerance for medical grossness after
decades of hospital stays and multiple family members who’ve suffered
terrible diseases, blanched and gently shuffled out of the room.
It’s weird to write about that, because I so frequently write about shit
torrents with the perverse delight of someone sharing that video from
The Ring, but in this case the endless bowel movement has a totally
different meaning. It means less pressure on the heart, less vomiting,
less compression of his remaining lung, less risk of crashing and even
death when we move him. It means the surgery can be performed with
better access, since he can lie on his side without his guts crushing
the breath out of him. It means Tiberius has a fighting chance.
Slowly his blood pressure continued to improve, reaching a plateau where
it took about two-thirds the amount of pressors to keep him trucking
along. Slowly the color came back into his cheeks. I worked up a genuine
Let me tell you, though, at the end of this stretch of shifts, all the
extra moving and turning—all the tight attention to detail and
moment-by-moment control-freaking—and, oh my god, the emotional support
for family? I was so exhausted I slept over the end of my break and, an
hour later, told my neighbor to watch my pts while I took a dump… then
slept on a sheet in the bathroom floor, something I haven’t done since I
was a night shift MICU nurse in Texas.
In Texas, which has no nursing union, breaks are “if you’re lucky” and
“thirty minutes per twelve-hour shift” and “absolutely no leaving campus
to pick up a burger at the all-night fast food joint, stay in the break
room.” The unit I worked on, bizarrely, had a strict no-sleeping policy
to boot, which meant that if you were nodding off at 0300 and you found
someone to cover your pts so you could wolf your lunch in the thirty
minutes you were allotted, you still had to stay awake in the tiny
stuffy closet-sized break room the whole time. Falling asleep could mean
a severe reprimand, or even an immediate termination. I don’t know how
the fuck they expected patients to survive with their nurses either
nodding off at the syringe or cranked up on stimulants nastier than
I spent a lot of ten-minute dump breaks passed out on a bathroom floor. I will never live in Texas again.
When I moved to my current state, which is unionized, I came back from
break still chewing my salad, only to be given a weird look and
instructions from my preceptor to go back and take the rest of my break.
Turns out, that facility usually takes a fifteen-minute morning break
and a forty-five-minute lunch break; others keep the lunch break at
thirty minutes, but add a fifteen-minute afternoon break. Night shifters
often pool their breaks to get an hour, or even an hour and fifteen
minutes if your facility rolls that way. And you can sleep. God, you can
So I sleep on most of my breaks, even now that I work days. I steal
five-minute chunks with a coworker keeping an eye on my pts, cram my
food into my mouth, then take a proper break to snore and drool on the
break room sofa. It’s amazing.
But man, Tiberius wore me out.
Since I was only working an eight, I wrapped up early, and at afternoon
shift change I started giving report while the evening RT went in to
check his vent settings. A few minutes later his alarms started going
off: oxygen desaturation, bombing blood pressure, volumes and pressures
on the ventilator messed up. I had removed his lidocaine patch from his
left shoulder a little while before, so I was freshly familiar with that
part of him, and I immediately spotted the way his shoulder was
The tension pneumo was back with a vengeance. Air was pushing up through
his flesh, inflating him with tiny bubbles that crackled where I
pressed his skin; his chest tube wasn’t tidaling at all. (Tidaling
refers to the rise and fall of water in the tube’s suction chamber,
which shows that there’s a pressure change in the tube as he breathes in
and out—that is, that the tube is still sucking air appropriately.)
The prickly pulm who’d been stripping his tubes wasn’t around today. The current pulm was not
comfortable stripping the tube, especially considering that he didn’t
know exactly how she’d done it before, and didn’t know that things would
continue to work that way. I called the CT surgeon, and soon the one
who’d done the initial pulmonectomy was at the bedside with the lanky
PA, Pilgrim, to place another chest tube.
Just as this happened, the charge nurse asked if I could admit in the
room next door. “Extremely no,” I said. “I’m supposed to be clocked out.
Do you know where the chest tube cart is?”
The flex RN, a sort of all-hands troubleshooter who (at this facility)
works like a dog all day, ended up landing that pt. I don’t even
remember what her deal was, although I took report on her while the flex
wrapped up her other duties, then passed off report during the chest
tube insertion. I think she was hypotensive.
They had paired him with a second pt for the night shift nurse, which
seemed cruel and unusual, since the other pt was having confusion and
agitation issues and needed a sitter. The night sitter hadn’t shown up
yet—was late, I think—and the day sitter had to leave to pick up her
kids, so the oncoming RN sat with (and blasted with Haldol) the agitated
pt while I dove in with the chest tube team.
I was okay with this, because if things started going south, I wanted
someone there that knew the little nuances of his issues and could milk
his pressors and sedatives for all they were worth. And I wasn’t done
giving report on him yet.
Pilgrim pulled the old chest tube, and they popped in another, which released the pressure with a huge pink-spattered whoosh
before I could hook it up to the atrium. Tiberius tolerated all of this
remarkably well, and the duo marveled as they cleaned up that they
couldn’t believe he’d made it through this latest setback and had
halfway expected him to die while they were putting in the new tube.
I thought about the bedful of shit and felt extremely smug.
Then I finished cleaning the room, because CT surgeons performing a
bedside procedure tend to tear up your room like a teenager’s mom
looking for skin mags, and lurched out into the hallway. The family was
in the middle of an impromptu conference with the pulm and CT docs,
white-faced and tightly nodding.
“We’re going to finish the thoracotomy tomorrow morning at seven,” said
the pulmonologist. “He can’t take many more setbacks. I think he’s about
as good now as he’s going to get, and if we don’t do this tomorrow,
unfortunately he will decline and probably die within the next few
His wife took a couple of deep breaths before she could speak. “What are his chances in surgery?”
“About fifty-fifty. Unfortunately, he’s had a very hard course with this
disease and I don’t think we can give him better than that.”
Physicians use the word ‘unfortunately’ a lot. Like ‘discomfort’, it’s a
way of recognizing that someone is suffering when you’re so accustomed
to human suffering that it’s hard to get a good perspective on this
particular case. Unfortunately, ma’am, your son passed last night. Is
that a bad thing? I don’t think he suffered much. Were you expecting it?
Was it kind of a surprise? God, I have no idea. He’s dead,
I packed up my stuff, checked on Tiberius, clocked out, checked on
Tiberius again, and left through the waiting room, where his family was
gathered. I don’t like hugging pts or their family, because generally
the hospital is a gross place and I have issues with being hugged by
people I haven’t learned to trust, but I hugged them all. They were all
crying, and I may have shed a few tears on my way out.
I made it home with a blank face, listening to podcasts about charlatan
magicians, and started chopping vegetables and rolling them up in foil
to be roasted over the campfire all weekend. You’re not supposed to take
your work home with you, because it will make you crazy, but sometimes
you really can’t avoid it.
You’d think it’s the tragic cases, the young people unceremoniously cut
down, or the old folks dying alone and slow because their family can’t
translate their love into letting them go; but man, the ones that get to
me are the ones where I put in real work. His chances are slim to none,
but by God I’ve squeezed those chances for every drop of advantage I
can get, and it’s been exhausting and terrifying and edge-of-my-seat the
whole way. I haven’t even let his family see, really, how close he is
to death at every moment, how often some small setback has made me
scramble. They know he’s not likely to make it; no reason to torture
them with the constant surge and retreat of miniature battles and
victories and losses. But every moment in that room, for me, was a
challenge: not to panic when things went wrong, not to lose focus when
things became tedious, not to slack off and cut corners and take risks,
not to forget to be a person and care for the family as well.
And now he’s out of my hands. I will be out in the woods, out beyond
phone reception, for the next five days. I am going from the front lines
to a position of complete helplessness, and it put jagged edges on all
my chopped vegetables and set my molars grinding. For a few hours,
standing in my kitchen, I got to experience the corner of what his
family must be feeling—he is in such a precarious place, teetering on
the edge, and I have to rely on others to be conscientious and critical
and skilled for his sake.
I have to remember that, even if everything goes perfectly right and everyone performs flawlessly, he will probably still die.
I don’t know how I’m going to sleep tonight.