Wednesday, July 22, 2015

Week 6 Shift 2

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 camping!”

“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 bouncing excitement.

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 caffeine.

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 sleep.

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 ballooning up.

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 days.”

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, unfortunately.

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.

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