Wednesday, July 29, 2015

Week 7 Shift 3

This shift did not start well. I gave report the night before to a nurse who has, best I can tell, the most brutal ball-shriveling resting bitchface I have ever seen in my life. Alex* is extraordinarily pretty, always immaculately groomed, incredibly capable and conscientious, and has the amazing power to make me feel like a feeble, wriggling brine shrimp during report.

“What have his sugars been running?” No eye contact.

“Oh, uh…” /checks the lab sheet “Not too high. Uhhh… One-sixties. See.”

Her lips thin out. “Mmmm-hmm. Did you cover him?”

“I gave him… uh… one unit at noon. And uh…. I didn’t cover his last blood sugar.”

Flat stare. “You didn’t.”

“No, it was… his blood sugar was like… one point above the cut-off. I didn’t want to crash him.”

“Mmmm-hmmm. So I’ll cover that, then, and recheck in four hours. When I’m supposed to. Did you get all the tubing changed?” Her expression is somewhere between of course you didn’t and I can’t fucking believe this.

“Yeeeeeah.” Then I wither in my seat and stare at my report sheet for a while. She never says anything hurtful or really judgmental, she just has a tone. Also did I mention she’s beautiful? That makes it a thousand million times worse. I always tell myself after report with her that I didn’t fuck anything up, that I did a good job this shift, that the things I didn’t get done were things I had good reasons not to do.

So, having given report on the crazy lady to her, I came back in a little terrified in case I had missed anything.

Instead, she informed me that she’d got a sitter for the pt again once her daughters had left for the evening—our night CNA who always stays over, Rose*—and that she’d really gone nuts last night. Great. Alex also said that she’d had two seizures last night, both of them beginning with the characteristic left-eye jerk that she usually pulled, and ending with tonic-clonic seizing.

She’d also had something that Alex described as “really weird,” an apparent syncopal episode. She’d recovered afterward, although her mental status was not so great for the rest of the night, but she’d gone apneic (unbreathing) and unresponsive for almost a full minute, and her heart had raced. Her post-ictal period had been extremely short.

“I don’t think it was a seizure,” said Alex. “She didn’t jerk her eyes around. But I don’t know what else it could be. Honestly? I was about to start coding her when she came to. The doc said that if she’s not back to normal by eight this morning, we’re going to start a bunch of lab panels and get a CT scan. Which won’t be fun, because she literally will not be still.”

Sure enough, she was fidgeting in the bed, occasionally mumbling to herself, pushing at the blankets with her hands and then pulling them back up. God, putting her in a CT scanner was gonna be hell. But hey, 0715, she had forty-five minutes to get some sunlight and snap out of it. My other pt was my little GI bleed fella again, so I got a ten-second “nothing new, discharge today” from the nurse and came back to see about getting my fidgeter out of sundown land.

Rose was a huge help. “We can just get her up to the commode,” she said, “and then maybe if she does well we can put her in the chair for breakfast, have her look outside. That should bring her around.”

So we hoisted her up to the commode, and she immediately dumped a gallon of dilute urine and let out a huge sigh of relief.

I fixed her gown. “Better?”

She nodded, then looked up at me with a puzzled expression on her face. “My name is Martha*,” she said, as if just remembering this fact.

“Yeah,” I said. “You ready to sit in the chair, Martha? We have some toast and scrambled eggs for you.”

A big emphatic nod. She looked really confused, kind of blindsided, and I didn’t blame her—if she was snapping out of sundowners, she would just now be entering the period where she starts genuinely waking up, the way I often stagger to the toilet in the morning without being quite sure whether it’s day or night. Rose helped me stand her up in the waltz position—her hands on my shoulders, my hands gripping her gait belt, my knees braced against hers in case hers buckle—and we started the process of pivoting to sit in the chair.

About halfway there, she made a strange expression. “My name is Martha,” she said again, and her pupils spilled wide, and her body went completely slack.

Rose and I barely kept her from hitting the floor, mostly by hauling on her gait belt and thighmastering her lower body with our knees up into the waiting recliner. She was completely limp, taking little hiccup-breaths, going gray in the face. Her eyes stared into the middle distance. “She’s having a seizure,” said Rose. On the monitor, her heart raced, then fell into a high bradycardia, rate of 55. Her bladder emptied. She wasn’t really breathing, and even the hiccup-breaths were diminishing into nothing.

We kicked the chair into full recline and I grabbed the ambu breath bag. “Check her pulse,” I said. On the monitor, her heart rate cruised down into the forties. “Check her pulse! Does she have a pulse!”

“It’s a seizure,” said Rose, but she fumbled for a pulse—wrist, throat, groin. “It’s just a seizure!” Meanwhile she kicked the bed into flat mode, max inflate, pulled the CPR board off the head, and slapped her walkie-talkie to call for a respiratory therapist and the flex nurse. We all do this: we say what we really hope is true, and the whole time we prepare for what we really hope isn’t true. Rose moves very quickly; the flex nurse, Franklin*, ducked into the room within seconds.

“You guys need help getting her back to the chair?” He looked at Rose prepping the bed, me bagging air into the pt’s lungs while still trying to find the flicker of pulse I’d felt before, and raised his eyebrows.

“Code,” I said. “Press the button!” Rose smacked the alarm and the whole unit dissolved into organized chaos.

“Jesus,” said Franklin. “You don’t fuckin do half of report, do you?” He dove over the bedside commode, nearly slipped in the lake of urine from my technically-dead pt, and helped me cradle-lift her in one adrenaline-filled swoop back into the bed, where we laid her flat and started compressions. On the monitor, her heart rate alarmed in the twenties with a wide complex—slow movement of electricity throughout the heart, a very bad sign—until we took up the lead-hammering pace of CPR.

Good pulses with compressions. The RT took over bagging. The intensivist—one I forgot to introduce before, a mild-mannered fellow with a soothing presence and a way with difficult families—pushed into the room just behind the code cart, which the charge nurse was plugging into the wall while Franklin stuck defibrillation pads to the pt’s chest. “What happened,” he shouted—codes are incredibly loud—and I told him the very short, very confusing story: she was on the commode, she stood up, she died.

We coded the ever-loving shit out of her. Pulseless Electrical Activity was all we got—not even a shockable rhythm, just that useless, flaccid bradycardia on the monitor with no physical pulse at all. PEA arrests tend to have incredibly bad outcomes; the heart is too fucked for the electrical system to even realize the muscle is dead.

In the middle of all this I walkie-talkied the unit secretary to ask her not to let any visitors past the desk for this pt. I mean, god for-fucking-bid that her daughters walk into this shit: their mother blank and staring in a bed, her few unbroken ribs mashing into pieces under my hands, blood foaming up in the breathing tube we’d just crammed down her throat, naked violent death at its least lovely.

Nothing worked. Nothing even started to work. Rose and I were both in a pretty bad emotional state—this was not the pt we’d have expected to code. For fuck’s sake, she had broken ribs and a UTI! And, okay, it looked like she’d thrown a clot and had a pulmonary embolism—the blood clotted in the tube as the lab tech drew it from her arm—and there wasn’t much we could have done about that, but I thought about last night’s syncopal episode and about the expression on her face as she died in my arms and felt absolutely, bottomlessly sick.

We called it after thirty-five minutes, a lifetime to code a woman in her eighties. The intensivist went in the hallway to call her family, and managed to get through to the two most anxious daughters, both of whom went completely to pieces over the phone. The other daughter wasn’t picking up her phone.

I arranged her as best I could, then took over the phone after the intensivist, calling the organ donation group (a legal requirement, typically to rule a pt out for donation) and the medical examiner’s office (another legal requirement, in case someone dies under suspicious circumstances or there’s a chance of hospital wrongdoing), trying to get the okay quickly to take the breathing tube and IVs out. You can’t take anything off or out of the pt until you get the ME’s okay.

While I was on the phone with the ME, the daughter whose phone had been off rounded the corner, ignored my attempt to flag her down, and pushed into the room. “Mom,” she started, then screamed: “Mom! MOM! Somebody help!”

God almighty, the unit sec hadn’t stopped her at the desk. Her sisters hadn’t got through to her either. She hadn’t answered because she’d been on the road, coming here, to visit with her mother over breakfast.

I’m just glad it was the more level-headed one. Of course she was devastated, absolutely wrecked—but she’s more familiar with death, and she was able to integrate it and understand it much sooner than her sisters would have. By the time her sisters arrived, I had taken out all the tubes and wires, brushed her hair, tucked her in, and had her looking halfway like herself again, except for a smear of blood beside her pillow that I covered with a washcloth.

I called the chaplain. Turns out the chaplain was off that day. The family hovered in the waiting room, terrified to go see their mother’s body, wailing and crying, at least one daughter nearly fainting twice. I called the weekend chaplain, who often covers on her days off, and asked if she’d be willing to come in and sit with the family while I finished up their paperwork and helped them get to a settling point.

She came in. I owe her big. Unfortunately, after she talked the family into going home and awaiting a call from the funeral home to go see her recovered body there, she hung around and tried to be emotionally supportive to me, at a time when I had a shit-ton of paperwork to manage and really wasn’t feeling terribly in need of a shoulder to cry on.

Mostly I was pissed as fuck, and frustrated, and I wanted to punch something. Every last fucking thing that could have gone wrong seemed to have gone wrong. I couldn’t believe she was dead; I could not believe that we had failed to keep her daughter from being surprised with her death. I was very polite with the chaplain, but finally I hid in the bathroom until she left.

Then I went into my GIB guy’s room for the first fucking time that whole shift. It was now 0830.

I gave him his breakfast, which was mostly cold by now, and took his blood sugar so he could eat it. I smiled graciously the entire time and apologized for taking so long. “I guess you heard everyone in the unit running around like crazy,” I said. “We were trying to save another pt who had taken a bad turn.”

He dug into his toast and asked: “Were they okay?”

“Not as okay as I hoped.” I don’t want to lie to people, but I can’t always tell them the truth, and either way it’s bad form to bomb somebody’s day with a spiel about how their neighbor just died.

As I emerged into the hallway, Alex appeared, expression of stern disapproval firmly in place. “That went badly,” she said, and I braced myself to defend my actions. “Here, I got you this.”

It was a Starbucks latte. A real, honest to god Starbucks latte. I am a little ashamed, but not much, to tell you that I got a little misty. “Thank you so much,” I said.

“You did really well,” she said. “I can’t believe she just coded like that. And her family… You handled that really well.” Then she left for home, while I sipped my latte and rejoiced in the knowledge that her chronic bitchface doesn’t reflect her actual opinion of me.

Ten minutes later, the guy showed up to carry Martha’s body away, and I finally gave the GIB guy’s morning meds and helped him to the bedside commode. I don’t mind telling you I was sweating like a horse the whole time. Waltz position and pivot, knees locked to knees, the whole time I’m chanting in my head: Please don’t code, please don’t code.

He didn’t code. He did shit an absolute lake of filth. I bet he felt better after that.

After this I took a nap. My blessed coworker and patron saint Mavi covered me for what we euphemistically called an “extended break,” and I spent forty-five minutes facedown on the break room sofa, dreaming about a bubble bath full of little adorable swimming mammals that would pop up through the bubbles and squeak, then dive like otters.

I awakened to the charge nurse shaking me gently. “Can you take the guy in twelve*? He has a sitter.”

Okay. Whatever. “What’s going on in twelve?”

“His nurse is getting a fresh VATS and he’s just… a little heavy.”

“Oh good. Sure. Whatever.”

He wasn’t just a little heavy. I mean, physically, he weighed maybe 200lb, but he was in four-point locking Velcro restraints with a bedside sitter and an ass full of Haldol injections. The dude is in his late twenties, a Type 1 diabetic, with a serious drug problem.

I don’t mean that he’s addicted to something, although I’m sure he is. I don’t even mean that he’s taking something nasty on the regular, although I’m sure he is. I mean that this guy will, apparently, do literally anything to avoid sobriety, up to and including begging Robitussin from a pt family member in the waiting room. I don’t think he even got enough Robitussin to get high.

And at any rate this was two days ago, when he was on the med-surg floor, before he went completely apeshit, ripped the whiteboard off the wall, threw a chair at his nurse, and ran down the stairwell to escape from the hospital. He was in for DKA and pancreatitis, and definitely didn’t seem to be in control of his faculties, so we hunted him down; he was in his truck in the parking garage, screaming and banging on the window because he couldn’t figure out how to get the door open.

He had taken a whole bunch of god-knows-what—tested positive for amphetamines, cocaine, opioids, and benzos, although the latter two he’d had in-hospital with his pancreatitis pain and his alcohol withdrawal. Oh yeah, his blood alcohol level was elevated too.

We weren’t able to figure this out until he had been thoroughly restrained, jabbed with an obscene amount of Haldol, shot up with about 4mg of IV Ativan, and strapped down while he drifted off into a mumbling daze. His blood pressure was out the roof—not uncommon for cocaine, especially crack, which we suspected because a) he’s homeless and poor as shit and b) he had a bunch of copper brillo pads in his passenger seat. He was also difficult to sedate, which we expect with meth usage… and he was insanely violent and psychotic, which we expect with the kind of bullshit gas-station drugs that get sold as ‘potpourri’.

I mean, he successfully tricked us into keeping him from being sober for another 12 hours. But he did not endear himself to us, what with all the punching and broken furniture.

By the time I got him, he was starting to calm down, and I was able to ease him off the restraints, although the sitter remained. His girlfriend came in, tearful, also obviously accustomed to sleeping in cars and shooting up, and I got her a sandwich and a warm blanket and told her to go ahead and sleep in the recliner for a while. When she woke up, her boyfriend was still semiconscious and mumbling, so she and I had a little contract chat: she goes to the methadone clinic, so I promised her that while her boyfriend was in the hospital, she could stay here and sleep in the chair and have three meals a day—as long as she attends her methadone clinic meeting times and doesn’t bring in any drugs or alcohol, which are absolutely forbidden on campus.

An hour later I caught her rolling a cigarette (no, not even a joint, a cigarette—loose tobacco leaves in a greasy recycled lunch-meat Tupperware), and explained that if she lit it up in here, the ceiling sprinklers would come on and drench everything. “It’ll ruin your phone,” I noted, and the pt spoke up from his groggy muttering to shout: “Put my phone in the drawer!”

I started to suspect that he wasn’t as gorked out as he seemed.

An hour after that I took his blood sugar and it resulted at 422. “What did you eat,” I asked him.

“Nothing! I haven’t eaten in, like, days.”

A cursory bed-shake revealed four full-sized Butterfinger wrappers and an unmistakable pile of Oreo crumbs. Like really, dude. We had a talk: “I know you want to get out of here as fast as possible, but you realize if you drive your blood sugar up, you’re just gonna end up back here, right? And if you have to have an insulin drip started again, you won’t be able to leave easily?”

He shrugged. “I’m leaving here tonight, even if I have to escape.” Big smile. “Hey, you wanna come with me? There’s always room in my truck.”

His girlfriend started complaining, then called me a whore. I left the room “to let you guys get control of yourselves,” and heard her berating him as I left.

“Why do you say shit like that? It’s not even funny!”

“It’s just my sense of humor, babe. Roll me a cig?”

God. Gaaaaaawd. By this point he was 100% conscious and aware, just being a total asshole. Every time I went in the room, he gave me a steady stream of “humor” about how he was leaving in an hour even if he had to hit someone, how the doctor had dropped by and said he could have dilaudid, how he would “sign whatever you guys say” to get out this evening because “I gotta meet a guy for some drugs. Just kidding!”

His expression didn’t say ‘joking’. His expression said that he thought I was stupid enough to believe he was joking.

A lot of people tell inappropriate jokes in the ICU. It’s a stress-coping mechanism, usually, if not a flattering one. A lot of people who feel out of control of their lives and bodies try to make the staff uncomfortable to re-establish their own feeling of autonomy. Typically I’ll handle this by setting strict boundaries, leaving the room with an admonition for the pt to get themselves under control, and looking for other places to give the pt some perception of autonomy. You can tell that it’s a stress response—they laugh with brittle force, they make lame uncreative jokes and remarks, they show their teeth and the whites of their eyes. There’s a little panic in their voices, a little aggression in their eyes.

Some people harass staff because they’re depressed, detached, feeling hopeless. They’re terminal, or their condition may never improve. They feel out of control, but they also feel like the world around them is hostile and unsafe. They self-deprecate as much as they attack; they have a bleak laugh, monotone voice, the kind of jokes that cut deeper than they should. They kinda joke like Robin Williams: all mania and grief.

(I could never watch Robin Williams comedy. He just looked so sad all the time. He looked like he was joking so he wouldn’t cry, or like he was trying to make someone laugh to keep them from swinging at him.)

These people need to feel control, but they also need to feel safe. They need palliative care, to help them find ways to live meaningfully at the end of their lives. They need a wry sense of humor to deflect their jabs, and to help their grim outlook become an enemy they can despise instead of surrendering to.

This guy… well. Some pts have zero intent of changing their lives, and resent being in the hospital at all. Some pts think they’ve tricked you, because here you are taking care of them when they hate you and would gladly hurt you if they could get away with it. Some pts think you’re a sucker, their bitch, their waitress; they make remarks and take potshots because they can, and they want to remind you that in their minds, they’ve already won.

I can’t stand pts like that. I hate seeing the expressions on their faces: the smirking challenge, the gloating, the certainty that they can get away with anything they try to pull. It turns my job from a joy and a labor of love into a gross afternoon of feeling wasted and exploited.

About an hour before end of shift, I got to give up my GIB guy and take on a new admit from the OR, a tiny old woman with Alzheimer’s who fell in her assisted living facility and now has a broken clavicle, broken facial bones, and a brand-new left hip repair. I barely had time to get her settled before shift change.

As I was waiting to give report, the afternoon charge came up to check on me. This is the same charge from yesterday afternoon, the one who knew my pt. “Oh,” she said, “did you transfer Martha to the floor?”

Explaining that was not fun.

After I gave report and was headed to clock out, I passed my tiny old lady from the other day, the one with the Diet Dr. Pepper and the razor-edged, if slightly unhinged, wit. “Hey,” she called, “can you come get these men out of my bed?”

“Which men,” I asked, poking my head into the room. She was alone, lying in a bundle of blankets.

“These men behind me,” she said, gesturing to the pillows shoved under her left side. “I’m all wore out! I’ve had enough. Tell ‘em to go home.”

I took the pillows out and told her the gentlemen wouldn’t be bothering her any longer. Then I made it halfway to the garage before I started wondering what, exactly, she’d thought those “men” were up to in her bed, wearing her out.

I hope I grow up to be an old lady just like her.

With an hour to go til report, I took a walkie-talkie call from the charge. “I need you to give report to Franklin on your GIB guy,” she said. “There’s a fresh hip coming up from the OR who went into a-fib on the table, and I need you to recover her until the nocs get here.”

“Shit, why can’t Franklin land her?”

“Franklin has the heart. So you’ll need to keep an eye on the GIB guy for him, and give your 1800 meds, because he won’t be able to get into the room easily.”

Sigh. “How about I just keep GIB for an hour and give report to the night nurse, and not waste time reporting to Franklin before the hip gets here?”

“Oh, could you do that? Thanks!” Click.

Yeah, whatever. GIB guy was happily chowing down on dinner, and I brought him his 1800 phosphorus-binding med (oh yeah, he was on dialysis too, and required medications to prevent his phos from climbing too high between trips to the fridge).

(The fridge here refers to the huge chunky dialysis machines that our dialysis nurses push up and down the hallways and use to scrub our pts’ blood. We call them “fridge nurses” and exchange good-natured jabs about the relative superiority of our respective nursing careers. Most of the hospitals in this area either keep their own dialysis fleet or employ the major dialysis-nurse agency in the city, which means that I’ve known most of them for years even though I changed facilities last year.)

The fresh hip was a little old lady with Alzheimers who had taken a dive while going to the bathroom and ended up with a broken clavicle, hip, and left hand. The stress of surgery had irritated the shit out of her heart, which went into a-fib, raising her risk of clotting. When the top chamber of your heart is just wiggling around ineffectively, it forms the perfect environment for clots to form—a warm, open compartment with walls that massage the blood rather than pushing it. And since she’d just had surgery, anticoagulating her was not an option.

So we started her on a diltiazem drip to slow her heart rate—she was quite fast—and laid her flat to recover. And then it was time to give report.

After which I went the fuck home and made dinner, checked with my sister to make sure she was doing okay at the GED tutoring sessions and to ask if she has an internship lined up yet, and then went out for an hour with my writing buddy to work on something besides a shift report: a highly simplified D&D campaign I’ve been running for some friends who wanted to learn tabletop RPGs but were intimidated by all the numbers and charts. It’s a small dumb thing that’s more story and flimflam than hard game-crunching, but I’ve been enjoying it, and it’s adapted well enough to a beginning group that it’s keeping ten simultaneous players occupied nicely. Plus my writing buddy is a game designer type so I can pick his brain for help when shit gets real, and he plays NPCs when I need them.

This is my first time DMing since I was in college. I am not good at it, I don’t think. But we have fun. 

5 comments:

  1. I'm sorry about Martha. There was no way to be prepared for her collapse, and it sounds like you did everything right. And I have an "Alex" at my workplace too. She's not so bad once you get past the bitchface. I know I can rely on her to do things right, and that counts for a lot.

    Speaking of D&D (on a higher note), this summer a group of my co-workers started a campaign. We're all horribly new to tabletop (except the DM) and the resulting hilarity is indescribable. Sounds like you're doing it right, too. :)

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    1. If you really want a more story driven plot for your DMing, I encourage you to look up the Planescape setting.

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  2. The code with Martha sounds nightmarish and I'm so sorry that happened. You did a fantastic job of handling it despite everything going to hell.

    The D&D campaign sounds like something I'd love. I've been interested in tabletop, and a friend of mine is trying to organize something online for it, but all the numbers and charts are hugely intimidating. I'm pretty sure there's a degree of dyscalculia at play there. You are amazing for providing such a great playing field for people who otherwise would feel totally shut out.

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  3. Awesome writeup Elise, and sorry about the awful code :(

    I've aways wanted to try a tabletop RPG, but it was hard to wrangle as a full-time student :P

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  4. Found your blog the other day and I absolutely love it! And now you mention D&D? Even better! Keep up the good work. Your writing is just so evocative, it's like I'm actually there.

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