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Thursday, August 27, 2015

A new post!

Late post! God, I hate working a huge raft of shifts in a row. Out of the last ten days I’ve worked eight, and tomorrow I go back for two more. You know what’s great? Having more than one day off in a row.

I came back the next morning and discovered that the supply-room coffee was even worse than usual, with a bitter, rancid edge that made it damn near undrinkable even with a carton of milk stirred into it, a petty-theft latte for the desperate. I coughed down a few gulps and rinsed my mouth in the sink, promising myself Starbucks as soon as I could get break coverage.

I don’t usually blow cash on Starbucks. I live a block from an independent coffeeshop that makes lattes to wake the dead, the kind of perfect espresso miracle that makes you sigh with relief every time you take a sip. It’s hard to get excited about the over-roasted stuff you get at the white-people-with-yoga-mats chain. God, I’m such a fucking snotty hipster these days I piss myself off.

(A week or two ago my husband and I dug an old, perfectly functional turntable out of the trash, bought a cheap pre-amp from an audiophile wizard of our acquaintance, and rifled a local yard sale for a few albums—ELO’s ‘Out of the Blue’, Tubular Bells, Neil Young’s ‘Heart of Gold’, and some Fleetwood Mac or other. We have been offending the neighbors ever since. This is probably a huge improvement over our usual evening soundtrack of Star Trek reruns, Bill & Ted’s Excellent Adventure, and Conan the Barbarian. The point is, we are now the worst kind of dad-flavored hipsters and should be euthanized for the good of society.)

But I can be as hipster as I want on my own time. When I’m working, I am 100% down for peppermint disks from the crystal dish in the conference room, PB&J in a paper cup with saltines, and the hospital cafeteria’s Clam Chowder Fridays. I have dumpster tastes and raccoon appetites and I belong out back of the Waffle House instead of in a high-tech facility for healing. Starbucks is outright classy compared to my workin’ self.

So it was quite a blow to realize that I was getting a pt who’d just landed fifteen minutes ago after having been airlifted from a smaller, rural hospital. Landing a critically ill pt—too sick to be managed by the local teams—meant I would be glued to the bedside, monitoring and giving meds and managing drips and performing all the little tasks that are so hard to adequately describe because they’re so boring. No time to go get Starbucks.

But if you can’t get coffee, adrenaline will do. I nabbed my stethoscope from my locker and headed down the hall with my pulse already picking up, seeing the cluster of transport techs and docs and nurses and other beasts swarming around my pt’s room.

Monday, August 24, 2015

Adjusting my plans!

Okay, so, that week off was desperately needed. I hadn't realized, but I was writing a ridiculous amount of verbiage, and it turns out that writing that much was a recipe for burnout.

Plus, I feel like you guys are starting to get the feel for ICU patterns: a little heart failure here, a little COPD there. Unusual things happen sometimes, between the cardiac caths and respiratory failures, but there are only so many times I can explain pressure imbalances or tell you that titrating vasoactive drips is both boring and strenuous.

So here's my new plan: I will post one shift report per week, based on the most interesting shift I worked, with extra coverage for any interesting short bits that happen on the other days. This will give me time to write another post every week-- a story, a piece of patho, or even an extra shift report.

I'll post the shift reports on Tuesdays, and the second posts on Fridays (Thursdays would make more sense except that my work schedule has me wrapping up a major week of work on Thursday nights, and I am usually dead by that point).

And yes, I will write up that one awful story. The first time I wrote it up, I wasn't satisfied with how it turned out-- clean-edged, internetty, and all about the shock value. I would like to rewrite it, and see how a year or two has aged it in my head.

See you all tomorrow night!

Saturday, August 15, 2015

I meant to post Friday, but I was so tired after that last shift that I fell asleep on the sofa and didn't wake up until 1030. Today is my one day off, and I got about half a shift written, so I will try to finish it up tomorrow after work and post it then.

Boy I tell you what, working more than four shifts a week is a profoundly bad idea for my sanity. Definitely gonna have to find a better balance so I can make the writing work.

Wednesday, August 12, 2015

Week 9 Shift 1

I showed up late for work by about five minutes, having lost track of time while I was standing in the shower performing my usual morning devotional of cursing, groaning, and ordering myself grimly to wake up, come on, you can do it.

Any time I’m late to work I sort of creep in from the staff elevators and try to sidle up behind the group report cluster without being seen. No luck this time—a bright-faced unfamiliar nurse called out: “You must be Elise!”

Turns out I was precepting today. Okay. Surprise?

Maycee has moved on to another preceptor—each new nurse gets two days with each preceptor, to make sure they get a good variety of teaching methods. I like precepting and am pretty good at it, but everyone learns differently, and I have precepted more than one person who wasn’t really meshing with my style and needed someone a little more methodical and hands-on. Today I would be precepting Anne, who loves airplanes and hiking and pictures of gross wounds, and who was very patient while I poured half a carton of milk into a cup of ditchwater coffee from the supply room dispenser, then thousand-yard-stared my way through the first half of it before my brain came back online.

Our pt was a tall, strikingly pretty older woman who had been very active and independent before she fell last night, smacked her head on something, and developed a huge head bleed—a subdural hematoma. There are several different types of common head bleed, and this is not usually the deadliest, but an SDH can really wreck your shit.

Monday, August 10, 2015

A night off

It's been one hell of a week-- I've actually worked five shifts in a row this week and am too tired to think straight, and as a result I've almost run out of my backlog of shifts. So I won't be posting anything tonight... back to normal schedule on Wednesday.

Man, who would have thought that writing three to four thousand words three days a week would turn out to be a pretty intense job?

Friday, August 7, 2015

Week 8 Shift 4 (I picked up an extra shift)

I didn’t sleep well after that last shift, and coming back in the next morning was an act of sheer will. This summer has been broiling hot, and I moved out of Texas for a reason, namely that for humans to live in Texas is an act of defiance against the great god Ra, and that if the away team of the Enterprise were to visit Texas in the summer they would refer to this entire world as a “desert planet” and four redshirts would die of fatal solar radiation. I did not move across the continent to a cooler climate so I could sweat like a wrung dishrag all day and all night.

One of my pts was exactly to my tastes: somnolent and needing very little intervention. She lives in an assisted living facility, where she’s mostly independent and hooks herself up to his peritoneal dialysis every night before bed. For the past few nights, though, she’s been “sick,” and hasn’t been running her PD, which has only made her sicker.

Hemodialysis involves sucking your blood out, running it through a machine the size of a Volkswagen that scrubs and washes and concentrates it, and pumping it back in to pick up more trash and water from your overloaded tissues. Peritoneal dialysis is a much less common form of dialysis, and one that doesn’t work for everyone, but which can be much less troublesome if it works right. A PD catheter is inserted through the wall of the pt’s abdomen, and dialysate fluid is pumped in and out, washing toxins from their body and blood through the permeable membranes of their gut. The fluid typically contains sugar, so pts have higher blood sugars on PD, but if it works for the pt… well.

After HD, a pt is typically sick as shit, often confused and shaky, usually weak and exhausted, and frequently nauseated. Regularly dialyzed HD pts tend to go in for a scrub three times a week, and with each round of HD the pt can count on being completely wiped out and useless for the rest of the day. This tends to really interfere in little things like “having a job” and “functioning for a majority of the week,” and that’s before travel time and expenses, interacting with health care staff (I will be the first to admit that we are terrible company), and having to rub elbows with other gross people from your medical community while hoping that they aren’t crawling with MRSA. So if you have the option of doing dialysis in the privacy of your own home, while you’re sleeping, and waking up the next morning ready to go about your day… PD is a total godsend.

The learning curve is a little high though. The pt needs to be thoroughly educated on how to maintain sterility, how to use and troubleshoot the machine, and how to recognize when something has gone wrong. A pt who skips days, who doesn’t follow up on appointments, who cuts corners—that pt is likely to have some really nasty outcomes. A PD catheter is a fast way to fill your belly with all sorts of microorganisms if you aren’t safe and clean with the thing.

Anyway, she had a UTI, which explains both the “sick” part and the reason she, a normally very sharp and independent older lady, made the very bad decision to stop doing dialysis rather than going to the doctor. Those of you with vaginas have likely experienced the burning agony of the UTI, with its bloody boiling lava piss and its ability to leave you feeling like you slept in a dumpster and were picked up by the trash truck before dawn. Sad fact: that shit is a blessing, because you think to yourself: gosh, I have a UTI, I should go get antibiotics. Older women are less likely to have the burning pee sensation, and sometimes their earliest clue to the presence of e.coli in their bladder is the fact that they lose their ever-loving goddamn minds.

That’s right: old ladies with bladder infections go fucking crazy. I’ve seen sweet grandmothers cursing and biting at their descendents, calm-faced knitters who turned into screaming paranoid kung-fu masters, and even a deacon’s wife railing about shit-eating demons crawling into her body and jacking off into her belly button from behind. Forgetting to plug in your advanced medical equipment is kind of tame in comparison.

But hey, no matter how well you handle a pelvis full of creepy crawlies, a few days without dialysis will absolutely make you loopier than a tatted doily, and sicker than shit to boot. This poor lady had no idea where she was or what was going on, except that she was nauseated and unhappy. I came into the room, scrubbing my hands with Purell and offering a chipper greeting, and she groaned and leaned over and barfed corn chowder down her shoulder and off the side of the bed.

There’s this thing, right, where you see or hear someone puking and you feel like puking too, right? I guess the evolutionary advantage is that, if your fellow cave-dwellers start horking up last week’s mammoth, you can get a head start on the mammoth evacuation process before the salmonella poisoning really gets a grip on your duodenum. Being a nurse for more than a few months will completely destroy that impulse. My immediate instinct when someone starts throwing up is to grab the nearest wad of laundry and jam it into the flood to keep it from spreading.

The last time my husband ate bad sushi, I nearly ruined our feather duvet.

God, the best thing about working in a hospital is that so much of the really gross shit gets done where I don’t have to see it. Laundry absolutely saturated with a grainy flood of shit? Put it in the big white bag and throw it down the chute and forget it! Pt took a whiz over the bedrail and threw his dinner into the results? Mop up what you can, and call the long-suffering housekeepers to do a bleach mop. I swear to god, I am not anywhere near this obsessively clean in my daily life, and I am 100% sure it’s because I can’t just page someone for backup whenever shit gets literal. I hope to sweet sainted fuck that the laundry is done by soulless aluminum launder-bots. I have this awful hunch, though, that it’s not, so I’m that picky nurse loser who separates all the plastic padding from the cheap muslin to minimize the necessary sorting before the blankets go in the wash.

But lord almighty, it is so good to be able to get rid of the stench immediately and start forgetting I ever smelled it.

A dose of Zofran and a housekeeping call later, the corn chowder was a distant memory and my pt was sleeping like your dad in church. On her left side, of course. The right lung is set at an angle that makes it easier for inhaled food and puke to slide down the right mainstem bronchus before you can cough it up, which means you want the right side elevated if your pt is at any risk of throwing up and drowning in it. Left side fetal position is often called the “recovery position,” because if you’ve had CPR or had a seizure or been very close to death, you’re likely to throw up at some point in the immediate future and you might not be awake enough to make sure it leaves your mouth and goes all over your nurse’s arm like it’s supposed to. (There are some other benefits to this position too, but my god, how much do you guys really want me to talk about hemodynamics right now?)

My other pt was a gentleman in for placement of an AICD, an automatic implanted cardioverter/defibrillator, which functions much like a pacemaker except that instead of reminding your heart to beat (although some of them do this too), it listens for your heart to have a dysrhythmic freakout and shocks the shit out of its unruly ventricular ass like a neighbor banging on the wall during a party. Pts who frequently go into dangerous dysrhythmias (also called arrhythmias), like ventricular tachycardia, or whose heart damage from MIs and heart failure puts them at high risk of deadly arrhythmias, get AICDs put in so they don’t suddenly die. If parts of your heart are especially irritable or not getting good communication with the rest of the heart, they panic and assume that they’re going to have to run the whole heartbeat show, and start yelling disorganized orders over the actual heartbeat signal. This can cause the whole heart to spasm and lose track of what it’s supposed to be doing, preventing it from actually moving any blood—this is called cardiac arrest. A good jolt of electricity stuns the panicked parts, giving the normal heartbeat a chance to pick itself back up.

That freakout is called fibrillation. The shock is called defibrillation. It’s one of the best tools we have for fixing deadly arrhythmias.

If the AICD shocks you, you know it. We get a lot of pts in because they were having Thursday night dinner when their AICD went off and kicked them facefirst into the meatloaf. Very uncomfortable and sticky.

So this guy had suffered a major heart attack that left part of his heart withered and necrotic—a part that, unfortunately, carried a lot of electrical impulse. As a result, one little area of his ventricles is now deaf to the electrical marching orders of the rest of his heart, and occasionally it gets the idea that it should be doing something and starts barking its own confused orders at its neighbors. He’s gone into ventricular fibrillation several times already, and had multiple rounds of CPR. Fortunately, since he’s been on the ICU hooked up to a heart monitor, we’ve been able to shock him immediately each time; the sticky electric-shock pads that we use to defibrillate him are just staying on his chest at all times now, until the AICD goes in. Because the defibrillation is happening very quickly and he’s only had to rely on CPR for circulation for a few minutes total, his organs haven’t really taken a lot of damage and he’s had good outcomes each time.

Despite three code blues this week with accompanying chest-crushing CPR, this guy is in good enough shape to be sitting in a chair, grumbling because he can’t have breakfast this morning. (No breakfast before surgery—anything in your stomach when you get anesthesia is going to be ejected at some point, and you definitely can’t spit your barf out while you’re unconscious, so breakfast before surgery leads directly to aspiration pneumonia and ARDS.)

When I walked into the room, he greeted me with one of my absolute least favorite quotes: “Hellooooooo nurse!”

Now, I get that it’s meant to be a compliment in some backward way. I understand that if you’re white and male and sixty-five you probably think the highest praise you can give a woman is aesthetic; you might even, if you’ve been reading a lot of noiresque literature, assume that complimenting a woman on her looks is a way of acknowledging her power and independence. But man, I got two problems with pts expressing attraction to me:

--I am pretty obviously not here to look hot. I am wearing pajamas, no makeup, an expression of exhausted patience, and about a pound of someone else’s bile. If you tell me I have lovely eyes with an earnest tone, I will probably accept that gracefully, because while I may check you extra-thoroughly for delirium I can at least appreciate that maybe you have strange tastes. If you react to my entrance like you’ve just been offered a hayjay by Jessica Rabbit, I’m gonna assume that your compliment is the disingenuous flattery of someone who thinks they’re gonna win my favor by introducing a sexual element to our professional relationship, and who intends to milk it for morphine.

--I am far from the most experienced nurse on the unit; I have about five years of ICU under my belt and I showed up for work in critical care two days after my NCLEX with dewy eyes and a trembling chin. But I worked obscenely hard to get where I am, both in my personal and in my professional life, and I am a formidable member of an elite team of life-saving medical staff, and to have that hard-earned accomplishment reduced to a catcall is absolutely intolerable. It reeks of disrespect and inappropriate sexual aggression.

This guy has had several rounds of CPR this week, though, so I gave him the benefit of a quick boundary: “That’s pretty inappropriate, would you like to try a different greeting?”

“Come on over here, little girl, and I’ll give you a different greeting.” Ugh. Uuuuuugh. At moments like this I just remember that I get paid not according to how many lives I save but according to how Disneyland-pampered my pts feel. I picture the dollar signs and bar graphs and ratings, and I grit my teeth and remind my pt that I’m here to provide him with medical care and that I’ll come back in a bit when he’s able to get his behavior under better control.

I’ve learned to be very comfortable with varying degrees of confrontation. I was raised, like many women, to think that the scale goes from “everyone is acting like nothing is wrong” directly to “EVERYTHING IS TERRIBLE” the moment a hint of conflict is introduced. Nursing has taught me that a little conflict in a conversation, like a little pepper on your scrambled eggs, is not only an acceptable thing but even a delicious thing—a thing to be savored, a thing that makes relationships and interactions exciting instead of bland.

I still have the instinct to flee, to placate, to absorb the unpleasantness and smile right through it. And I do keep my smile, and behave politely; but I also have learned to say, That’s super awkward of you, aren’t you embarrassed, and to tilt my head and smile with my eyes and watch that asshole twist.

This was a theme throughout the day. It got very tedious.  

My PD lady continued to vomit, and the doc ordered her an MRI with contrast, which meant I had to take her down to MRI for a full forty-five-minute scan without letting her drown in her vomit. I loaded her with Phenergan, popped a scopolamine patch behind her ear, and borrowed a subglottal suction catheter so I could keep her mouth empty if she vomited while I couldn’t reach her.

Then we moved her down to the MRI chamber and loaded her into the tube. The suction system in the MRI chamber was doing something really weird—like most hospitals, ours has been forced to prioritize its expenses, so some non-critical systems are a bit primitive—so I hooked a big syringe up to the subglottal catheter and stood by her feet as she went into the tube, watching and listening for any signs of vomiting so I could hand-suction her mouth.

The MRI is so loud. I was wearing earplugs and the sound went through me like a bore hole to the terrestrial mantle. If you’ve never heard this sound, I urge you to hit up youtube and have a listen, because no words can do it justice: clanging and crashing, and an all-consuming power-chord thrum of metallic force: DAH DAH DAH DAH DAH. DUM DUM DUM DUM DUM. DRRRR DRRRRR DRRRRRRR.

 It jarred my teeth. My feet ached with the force of the noise. There is an arcane quality to it, a rhythmic intent of pure alien purpose that wants nothing of your sanity and only stops to breathe when it’s finished its task.

While I was in the MRI, my annoying pt was shuffled off to have his AICD placed, and as I returned to the unit the charge nurse told me he would go to the special care unit after the procedure.

So by the time my PD pt was settled, I was ready to take another pt: a craniotomy who had fallen in her home and developed a subdural hematoma. After surgical evacuation of the blood blister inside her skull, they brought her up to me intubated and sedated with a C-collar to keep her spine immobilized. We hoped that the pressure damage to her brain wouldn’t be fatal, but there’s really no way to tell yet, so we’ll wait and see how the swelling goes, and support her medically until then.

She has fake breasts. They are extremely rigid and strangely shaped. The CNA and I noted this and carried on; we see many pts with breast implants and other surgical reconstructions, and I have long since learned that as soon as you start judging a pt for some seemingly voluntary aspect of their looks, you’ll discover that they had reconstructive surgery for cancer or some other thing that makes you feel like shit, and deserve to.

So we made sure that everything on the bed was arranged in such a way that visitors couldn’t see either her nipples poking through the gown, or the unnatural rigidity and wide placement of the breasts themselves. I’m certain that this woman spent a great deal of effort in making her breasts look natural, and it would be cruel and spiteful to let the secret out if she hadn’t already told any of her guests.

It feels very strange to carefully pad a pt’s breasts, let me tell you. I felt a little gross and intrusive. But even if she got them for purely cosmetic reasons, it’s her body, and I wouldn’t leave an embarrassing tattoo out for the neighbors to gawk at either.

The MRI showed no signs of anything wrong in the PD lady’s belly. Thank goodness, she just needs lots of dialysis and antibiotics; we can have her fixed up and home by the weekend. The dialysis nurse dropped by just before shift report and started her on her nightly PD, and I hope that by morning she’s closer to her normal self.

During report, my pt from the last two shifts, the sepsis pt with liver failure, died. An estranged sister had got in contact with us and given us the okay to allow him a natural death according to his wishes, and they turned off the drips, loaded him with painkillers and benzos, and pulled the breathing tube. He breathed on his own for ten minutes, then slipped away gently and comfortably at last.

I am glad for him. He earned his rest.

And after this shift, I’ve earned mine too.

Wednesday, August 5, 2015

Week 8 Shift 3

Day two with Maycee. Somehow she survived her first shift and is back for more, and even looked a little energetic during shift change, which was downright irritating for me because I hadn’t had any coffee yet and felt like a lake of lukewarm shit. Fortunately our unit has free (terrible) coffee in a truck-stop-style machine in the supply rooms, so I was able to get my smack-and-wince dose of caffeine before my ability to feign personhood ran out.

I wasn’t always such a complete caffeine junkie. On nights I rarely ever drank coffee because it fucked up my sleep schedule so badly. Nowadays I can’t get through the morning without my usual half-cup mixed with a stolen mini carton of milk, and I drink the second half-cup cold and kind of stale-milk-tasting later in the afternoon. It’s not much caffeine, but I can’t do without it.

This disturbs me.

Maycee was drinking some sort of sentient green morass out of a Nalgene bottle. It smelled like algae and pineapple. It’s probably some healthy superfood thing I should be drinking instead of a paper cup of two percent and bean tar.

We took report from that one nurse again, the one with the propofol tubing fetish. He was still bitching about the damn tubing. I mean, I have been taken to task by some nurses for stupid things, but by this point I was a little embarrassed for him, especially since the pt we were taking back had been down to almost no levophed at all when we passed him off and now he was cranked up to a stupendous dose, his urine output had been trending downward for three hours with no MD notification, and he looked sweaty and shitty and filthy because apparently that bed bath he’d tried to trick Maycee into was the only bath he got all night.

Night shift nurses do the official bed baths, especially on vented pts. Whatever. I used to be a night nurse and I still have a Thing about my pts being clean. We opened up our shift with a stiff, polite nod to the departing nurse and then a proper bed bath for the pt.

We only had the one this time. Thank goodness—I planned to have Maycee assume all of his care today, and that would be completely impossible if we were running back and forth between pts all day. The neighbor, the humongous guy with diarrhea who was (also) wrongfully intubated, is still doing his thing and I still got to run in every twelve seconds and fix his IV so he could keep getting his sedatives, but we were able to focus mostly on the liver failure/sepsis pt and his increasing needs.

He was not getting at all better, but then again he wasn’t doing anything flashy either. He had high gastric volumes (amount of stomach juice that wasn't moving from stomach to intestine) so we couldn’t start tube feeds; he had lots of fluid in his abdomen so we ended up doing another paracentesis for another 6 liters. Since he weighed in at about 15 liters up this morning, in excess of his base weight, this was less impressive than I could have hoped… but there’s something deeply satisfying about watching all that gooey liquid pour into the suction canister, knowing that we’re cheating the body’s self-destructive excesses and recovering the balance.

A friend of mine observed this recently: a lot of what we do in the ICU is simply keeping your body from killing itself. Many of our natural processes are totally normal and productive at low levels: swelling is an important part of washing out infected or traumatized areas of the body, clotting keeps us from bleeding out, fevers fight infection… but at a critical level of acuity, those same processes become a potential death sentence. Inflammation crushes our bodies, deforms our tissues, drains the liquid from our blood; clots occlude our arteries and contribute to adhesions and use up our platelets where they aren’t needed; fevers cook our brains and organs like gently poached eggs.

Past that threshold, the body can’t heal itself effectively. It’s a last-ditch effort, a forlorn hope: maybe another half a degree will stop the bacteria, and we can rebuild the damage later, maybe, or live without the ruined parts. Maybe a little more swelling will give us the edge against the infection, and maybe we can catch up on blood volume later. Maybe this clot will be the one that heals the damage.

If this one doesn’t work, we die anyway.

But then here comes modern medicine with its antibiotics and other weapons of microbial mass destruction, ready to save the day, if only we can get the body to stand aside and let us do the work. Septicemia? Sure, we have an antibiotic for that—one bug, one drug. Maybe two or three, if we can’t figure out which thing we’re fighting.

But while the vancomycin and piperacillin and ceftriaxone are working perfectly well and the invaders are in fast retreat, the body is still fighting as if it’s alone on the field. So we give drug after drug to support the body through its berkserk phase: liters of fluid to replace losses, pressors to keep the fluid where it belongs, blood-thickening albumin to draw the swelling back in, diuretics to pee it off; steroids to interrupt the cascade of inflammation, blood to counter the dilution and make up for the body’s deficit while it focuses on white blood cells instead of red. Heparin to keep the immobile body from clotting. Bicarb to counteract the acid produced by stressed cells.  Mechanical ventilation to keep the swollen lungs functional and increase available oxygen. Proton pump inhibitors to prevent ulcers and acid reflux while the body is stressed and ventilated. Chlorhexadine mouthwash to keep other germs from crawling down the breathing tube.

It’s insane. If we can naturally produce the antibiotics we need as soon as the germs invade, antibodies with the right markers to identify their enemies immediately instead of mounting a full septic assault, we don’t need any of the other drugs. If we can interrupt the sepsis early, before the inflammation gets out of control and the body’s organs are dying from low blood pressure, we don’t need the ever-increasing volumes of supporting drugs to deal with the consequences of sepsis. And if our bodies can’t control the infection and our doctors can’t keep our bodies in check, we die.

Nothing in nature prepared us to survive things like this. When we save someone in deep sepsis, we are fighting more than germs, more than poisons: we are fighting human history, evolutionary pressure, nature itself.

I have no problem with this. Nature is a bitch. Tumors are natural; epidemics are natural. I am perfectly comfortable fighting nature, as long as we remember that the battle is fought on many fronts and that winning the battle with sepsis doesn’t always mean winning the battle against organ failure, old age, lingering infirmity, and pain. So yes, absolutely, I will fight nature bare-fisted and without shame—but I know better than to gloat over my victories.

All this makes it very hard, emotionally, to care for pts who are doomed. This poor guy never wanted to suffer like we’re making him suffer: he wanted four days, max, on the ventilator, and here we are punching holes in his belly so his weeping, failing liver can get some relief, days beyond his deadline. It’s fucked up and awful and out of my hands. It’s a very American way to die.

Fortunately the ethics committee is involved in this one, and we’re hoping for permission to withdraw pretty soon. Until then, you had better fucking believe I’m blasting him with fentanyl. If he’s got to stick around for this shit, he’s gonna be oped up to the eyelashes the whole time.

Maycee performed most of his care today. I helped with turns and assisted whenever asked, but I let her try things out, make mistakes, and zero out her pressure lines by herself. She did wonderfully, and between chores we exchanged war stories of hospital life.

Having worked on the telemetry unit until now, Maycee’s patient loads have been three and four pts to a nurse, and none of her pts are sedated or on titratable drips. She also worked nights, which means she got to see pts at their weirdest and most whacked-out—a thing I kinda miss, now that I’m days.

She described a group of three sundowning pts whose rooms were unfortunately close to one another, all of whom spent all night yelling at each other. One was a tiny old lady who constantly demanded: “Who’s there? Who’s there?” Another was a little old lady who cursed and screamed for “them” to leave her alone. The third was a developmentally delayed man in his forties who called out for help with almost every breath he took. Two could be redirected temporarily with a bit of soothing company, but the paranoid old lady got worse every time someone came into the room, and the other two responded to her bellowing with a litany of responses: Who’s there? Help! Who’s there? Help me!

All night they kept this up. If one of them fell asleep, the others would wake them back up. Closing the doors increased the screaming—a lot of delirious pts are terrified of being enclosed. Maycee related the charge nurse’s ongoing battle with Bed Control and the shift administrator, as all three pts needed to be close to a nurse station for observation, and breaking them up would involve transferring at least one of them to another floor. Finally the shift admin dropped by to have a face-to-face chat with the charge, observed the noise firsthand, and had transfer orders for two of the three within thirty minutes.

I laughed my ass off, naturally. We’ve all had nights like this, and we’ve all begged distant, uncomprehending administrators for mercy the way prisoners wish upon stars. Any story where someone doesn’t believe a nurse until they see for themselves is a relatable story; any story where the unbeliever is driven mad, splattered with body fluids, or chewed out for their disbelief is a great story. We are nothing if not predictable.

Well. Maybe we’re also bloodthirsty and petty. But we’re predictably bloodthirsty and petty.

I told her about a pt I had in Texas, a woman whose panniculus obscured her legs down to the knee, whose labia majora were distended with edema and obesity to the point that they looked like sagitally aligned panniculi on their own, and whose foley catheter placement was an effort of legend. We used a hammock-style bedsheet hoist to restrain her panniculus and lift it toward the top of the bed—a sheet folded lengthwise, tucked under the hanging gut, threaded through the bed rails on either side and pulled back to achieve a primitive pulley effect.

She had been an uncontrolled diabetic, as I recall, and had a raging raw yeast infection downstairs. I felt fucking terrible for her—she had not been taken care of at all, and was well past the point where she could take care of herself. As we struggled to hold her labia back, she sobbed and hissed with each pressure of a glove against her bleeding, excoriated skin. I had one coworker holding each labe, and I was wearing long gloves and squinting at the bloody, curdled mess of her vaginal vestibule, searching for her urethral meatus—

When one of the coworkers started to lose her grip. “Get out,” she barked, understandably not wanting to grapple with that incredibly painful stretch of skin for a better hold; I got my arm out of the way just in time, as did the other coworker, and the two labia slapped together the way you might clap dust out of a couple of rugs. It sounded like somebody had dropped a fresh brisket on the linoleum. Yeasty effluvium launched from between the folds like taffy thrown from a parade float. All three of us caught a little bit of the splash; I was spackled from my right elbow all the way up to my left ear.

And man, what do you do with something like that? I mean, you can’t really laugh that shit off until you’ve had a chlorhexidine shower and a glass of gin. You sure as fuck can’t freak out and gag and cry and curse, because your pt is right there and no matter how gnarly her vagina is you don’t want to be the dick humiliating a sick woman for being half-eaten by yeast. You can’t even really process it. You assess the damage—did any of it get on my mucus membranes? Do I need to control any secondary drippage? Will I need to get some fresh sterile gloves?—and if you’re not in immediate danger, you just take a deep breath and get back at it.

I do remember reassuring her that I would get her a topical treatment to help with the pain and itching, and that she was extremely relieved once the foley was in and she wasn’t trickling hot urine over her raw, infected skin.

She actually ended up doing pretty well, as I recall. She came back to the MICU three weeks later after a panniculectomy and double knee replacement, and was able to walk a few steps on her second post-op day. I hope that gave her a chance to turn her life around.

After our second-to-last turn, I was tapped to watch a pt down the hall while his sitter was on break. Fifteen minutes of watching a little old guy scratch his balls and ask whose garage he was sitting in? Sweet. We had a great conversation about carburetors, mostly consisting of me having no idea what the fuck a carburetor does and him explaining it to me four times without making much sense, and then he looked me in the eye, lifted his wrist to his mouth to cover a yawn, and pulled out his IV with his teeth. Blood went everywhere. I stanched the flood, paged IV team, and apologized to his nurse for my utter failure as a sitter.

Turned out this was his fourth IV that day. I hadn’t known, when I started sitting him, that his IVs were supposed to be wrapped in an obscuring bandage at all times, and apparently while the sitter was handing off to me he’d unwrapped his line and thrown the bandage on the floor all sneaky-like. Some pts are crafty lil fuckers, I don’t care how confused they are. It’s kind of impressive, really. I don’t know if I could come up with a plan that effective, and I’m not even tripping Haldol-pickled balls on the ICU.

Toward the end of the shift, the abd guy started having a lot of trouble. He had gone down for surgical placement of a tracheostomy and PEG, and I guess he’d been fine for most of the day. During the PEG placement, it seemed, they had insufflated his abdomen—pumped it full of air to allow free movement—and the leftover air was causing pressure issues. He ended up having what I can only describe as an abdominal needle decompression, the way you decompress a tension pneumothorax, and the catheter in his belly farted as they rolled him back and forth to work out all the air.

He nearly coded, apparently. I have never seen anybody react that harshly to insufflation. It’s not like they leave you all blown up. I guess he was just hoarding air—his abdomen is probably a maze of adhesions and scar-pockets by now. Once they decompressed him he was perfectly fine, and even came to enough to open his eyes and move his mouth in voiceless ba ba ba syllables, singing to the ceiling.

Today they started talking to rehab facilities to see if we can get him a bed with Kindred or one of the other long-term care places.

We wrapped up the shift without any more remarkable occurrences, and after running over the day’s events with Maycee, I signed off as her preceptor and gave her full marks for work well done. She will work with a couple other nurses before they start giving her pts of her own. I look forward to seeing how she grows as a nurse. She’s pretty cool.

Regarding the story I mentioned last time, the man and his mother and the cats: I honestly didn’t think this blog would be popular at all outside of the people who already read my forum posts, and they already know that story. I might post it here at some point this weekend, but I want to give a couple of disclaimers:

--It’s definitely the worst thing I’ve ever experienced as a nurse, and hopefully the worst thing I ever will. It’s not the kind of cool story you want to gross your friends out with; I still find it distressing and disturbing and almost sacred in its awfulness, like retelling it is some kind of violation. But I also know that it’s a real thing that happened, and that storytelling is one of the ways we give awful things meaning beyond tragedy, and that some of the things we should fear most are simply hidden from us because they’re too awful to discuss. So I might post it anyway.

--I will definitely have to figure out how to hide it behind a read-more link first.

Monday, August 3, 2015

Week 8 Shift 2

The new crop of ICU nurses is coming on this month. We’ve recruited our usual blend of experienced RNs from other facilities across the country, pre-trained travel RNs who’ve been seduced onto full-time jobs after finishing their contracts (I was one of these), and PCU/PACU/telemetry RNs who are excited to move to the ICU and learn the ropes. The latter group requires a hell of a lot of attention before they’re ready to be turned loose on patients.

When I entered the world of the ICU, I was a new grad, fresh off the NCLEX. I knew I wanted to work ICU, and I had done a lot of high-focus work in school to get there, but I was in absolutely no way prepared to actually provide critical care. I don’t know why they hired me—I probably smelled like amniotic fluid and fresh hay, sitting across the desk from the manager with my incisors clamped together and my lips peeled back.

As it turned out, they were desperate. A mass exodus of nurses from their MICU had made conditions very tight there, and I suppose everyone figured it would be easier to foist off the low-acuity pts on a clueless tottering foal of a nurse who probably wouldn’t kill them than it would be to suffer through another month of catastrophic short-staffing. And, I mean, I’m pretty good at making competent faces.

Fortunately, I had excellent preceptors. I sat through two weeks of class, then another week of computer training, then started two weeks of precepting—following an experienced nurse through the care of a single pt, slowly learning the ropes and getting used to all the drips and rhythms and schedules and reports. At this facility, new nurses are precepted for up to three months; at my initial facility, I had two weeks on days, one week on nights, and then a full pt load. I don’t know how I managed not to kill anybody.

I probably did kill some people. Not immediately, but by providing less-than-competent care that didn’t give them the foundation they needed to heal. I over-sedated my pts—to be fair, we all did this—and I often ended my shifts completely confused and with so many chores left to do that I was the terror of the day nurses who had to follow me. I was Not A Good Nurse.

So precepting is really important to me, and I came to work early because I knew I would be teaching someone how to ICU today.

Her name is Maycee*; she is tiny and energetic and has the cute kind of freckles that speckle the bridge of her nose (unlike my all-over sepia dapple that looks like an old-fashioned Instagram filter of a nasty crime scene under blacklight). She has only ever worked telemetry until now. She’s quite smart and used to hard work (tele/progressive care nurses are some of the hardest workers in the hospital), and so I didn’t feel too overwhelmed when they told me we’d be caring for two pts instead of the traditional precepting one.

This is actually an intense load. You can’t just do anything—you’re explaining all of it, the principles behind it, the rationales for your actions, the processes you used to arrive at your decisions, the whole time. You have to ask leading questions and see if your preceptee can follow those routes on their own, which means setting up a decision situation, prompting the preceptee with a question, and taking the time to gently prod and guide them until they answer the question on their own. It basically doubles the time anything takes, which means that taking two pts is an absolutely mind-blasting time-management gauntlet.

One pt was a desperately ill pt with liver failure and sepsis who had, before being intubated, said that he didn’t want to be intubated for more than four days, and who was now on his fifth day with no family members to follow up on his wishes. The other had chronic worsening respiratory issues and hadn’t wanted to be intubated at all, but had been found down by a neighbor who didn’t know his end-of-life wishes, so he’d been tubed and brought in by the EMTs and was now in full-code hell waiting for some family members to get back to us and let us put him on comfort-only care.

This has been somewhat of a theme on our ICU lately. It’s discouraging. I hate to imagine being chronically ill, having no chance of recovery, and being forced to stick around and suffer because nobody can speak for me.

By the way, DNR tattoos don’t count. DNR papers, signed by a physician, are good for something if they’re posted where the EMTs can see them before they get the tube in and start CPR… but they aren’t allowed to pull the tube out or, in many cases, stop the CPR once it’s started. If you really don’t want to get beat up before you die, it’s a good idea to get the signed papers and put them just inside the front door, and maybe to get a med-alert bracelet instructing any rescuers to look at your papers and/or call your POA (power of attorney) person.

Our pt was on levophed, which meant his pressure was okay, but his arms and legs were enormously swollen. He was up by nineteen liters of fluid from his admit weight. We diuresed him as much as possible, using albumin between rounds of lasix to suck the fluid back into his bloodstream from his tissues. An hour into the shift, we started a lasix drip. We also had to keep him on a continuous potassium drip, as lasix works by dumping potassium to force the kidneys to dump water as well (in simplified terms, anyway).

At max rate, the lasix got his kidneys up to a break-even point where he was peeing about as much as we gave him every hour, except hours where we gave him antibiotics or literally any other fluid above and beyond his continual IV drips.

Meanwhile, the guy next door required frequent bolus doses of sedatives to keep him comfortable, and was shitting more or less continuously. He weighed a fucking ton, so we were relieved to discover that his room was one of the two-thirds on our unit that has an overhead lift by which we could turn and haul and move him. It didn’t really help a lot with cleanups, since it lifts pts by hoisting the corner-straps of a mesh hammock the pt is lying on… so if you need to clean the pt’s butt, you have to move the hammock out of the way. But it made turns a thousand times easier.

Our liver failure/sepsis guy was really not doing well. His PEEP had to be cranked up; he was so fluid-overloaded his lungs were flooding, and the high doses of levophed provided even more systemic resistance that backed up into the left side of his heart. I’m not actually sure if this is true, as I haven’t fully researched it, but I’ve heard that levophed and phenylephrine in particular contribute to pulmonary hypertension by squeezing the lung capillaries, which causes the same swelling in the lungs that happens in the hands and feet with those drugs.

Either way, I can tell you that a pt on a high dose of levophed isn’t going to be breathing on their own for long.

(The hand and foot swelling comes from the way levophed closes up your peripheral blood vessels, resisting blood flow to those areas so that the blood is redirected to critical organ circulation… but also impeding the return flow of fluid that actually makes it out that far.)

So we had him on a whalloping fourteen of PEEP. I can’t remember if I’ve explained PEEP before, but I am the kind of person who precepts well because I can’t stop myself from ranting, so buckle the hell in.

PEEP stands for Post-End Expiratory Pressure. If you just breathe all the way out at the end of each breath, the little air sacs in your lungs—the alveoli—can collapse at the end of expiration. And because the inside of each alveolus has to be wet and gooey with lung-mucus to allow oxygen to diffuse across the membranes, the walls of those little sacs stick together when they close—especially if there’s lots and lots of goop, ie lung boogers or edematous flooding.. It takes a shit-ton of work to force those stuck-shut alveoli open again, and until they pop open again, they aren’t exchanging any air. It’s better to keep them open in the first place… but how?

As a bonus, if your alveoli are swollen up with too much water, they might stop working properly—in which case you gotta bring that swelling down. Diuretics might work if it’s a systemic overload problem, but if your lungs are just irritated and inflamed, you need to find another way to squeeze the fluid out. If you’ve ever had a sports injury, you know that compression helps a lot… but how are you going to squeeze your lung tissue?

The answer to both of these questions is PEEP. At the end of each breath, a sharp puff of air forced into the lung keeps the interior pressure of the lung juuuuuust high enough to prop open the alveoli, and maybe even force a few closed ones to reopen. And by maintaining pressure on the alveolar tissue, PEEP compresses the swelling, forcing fluid back into the bloodstream so your heart can pump it and your kidneys can dump it.

There’s a problem with PEEP though. And we ran into it almost immediately, as our pt suddenly bombed his pressures and had to be given albumin, then cranked up on his levophed even further. Why was this happening, I asked Maycee?

She pondered this for a while. It’s not an easy concept to grasp, and I was asking her to piece it together on her own. I hinted that it had to do with pressures and pressure imbalances in the thorax, and she worked on that until I could see her brain sweating. At last she ventured: is his heart not making enough pressure?

Yeah, I said. There are three reasons why the ratio of pressure involving the heart might be off. The heart itself might be having trouble generating pressure; the pressure beyond the heart (either in the body or in the lungs, the two areas the heart empties into) might have spiked, making the heart’s normal pressure insufficient compared to the new resistance; or the heart might not be getting enough pressure supplying blood to it. Or a blend of these things—it’s rarely just one.

Had we recently changed any pressures in his body?

Any post-end expiratory pressures?

At that point she got it, and it was amazing to watch the string of lights behind her eyes igniting a trail from one concept to the other. “More pressure in his lungs from PEEP,” she said. “More pressure for his his heart to push against; more pressure to resist the flow of blood back to his heart from his body. We changed the pressure! So can we fix that?”

The answer is complicated. More fluid in his bloodstream would increase the return pressure to his heart, but stood a good chance of never making it back to his veins after the pressure in his arteries petered out, and he was already desperately fluid-overloaded. He had run out of places to put extra fluid; his arms and legs were weeping and taut, his scrotum had inflated to the size of a basketball, and his belly was a distended, thumpable tank of fluid that had oozed from his liver into his abdominal cavity.

And honestly, you can only give someone so much levophed.

So we called the charge nurse and asked if we could hand off the other guy at 1500—the answer was yes—and then called the pulmonologist/intensivist, our brilliant and beloved Dr. Padma, and asked if she felt like tapping this guy’s abdomen.

She agreed with us: we needed to get some fluid off this guy, and a quick bedside ultrasound showed that he had too much fluid in his belly to measure easily just by looking at it. She said she would go finish her rounds, then come back after shift change.

I sent Maycee on an extended lunch break. It’s hard to absorb all the things you’ll see in an afternoon on the ICU if you’re not used to it, and I firmly believe that part of the learning process involves time spent staring at the wall, trying to piece all the memories and ideas together. By the time she got back, it was ten minutes after shift change, and I had the room more or less prepared for the paracentesis.

Dr. Padma set up a paracentesis kit at the bedside, and we watched as she used the ultrasound machine to guide a needle into a fluid-filled pocket of his abdomen, thread a hollow plastic catheter over it, then withdraw the needle and leave the catheter to drain.

The bag that came with the kit filled to its total—a liter—almost immediately. We emptied it, then drained some more, then realized that this was going to continue for some time. So we hooked the catheter up to a wall suction canister, turned it to low suck, and changed the canister every time it filled up.

The fluid was thick and gooey and wheat-colored with a pink tinge. It also foamed as it poured into the canister, forming a thick layer of bubbles at the top that forced us to empty the one-liter canisters whenever they hit 800mL. I explained to Maycee that the foaming came from protein dissolved in the fluid, a common finding in ascites runoff. Albumin—yes, the same protein that we give intravenously to thicken up the blood and draw in fluid from the third space—is essentially the same thing that you get in egg whites, albumen, which means it foams up nicely when agitated.

I pointed this out to Maycee, and added that you could probably make a decent meringue out of the stuff. She tripped over a gratifying dry-heave and then spat in the sink. “That’s fucking gross,” she said, the first time I’d heard any real language out of her, but her tone of voice was not one of censure.

I mean, you probably couldn’t make meringue out of it. Any decent cook can tell you that any kind of lipid or protein impurity in the albumen can keep the foam from locking; additionally, the acid-base balance of ascitic fluid is more likely to be alkaline than acidic, which means you’d need a lot of cream of tartar to make the foam stable.

Either way, the gates of gross stories had now been unlocked. As we removed liter after liter of fluid from his abdomen—we totaled at nine and a half liters—she told me about a pt she’d had once with severe osteomyelitis in a leg-bone exposed by rotten diabetic flesh, who refused amputation until the doctor reached into the wound and squished the bone audibly, pointing out that it felt like soggy Triscuits.

I told her that one story about the guy and his mother and all the cats, and she called bullshit, which is an appropriate reaction to a story that grim (I will probably never have another story to rival it), but I texted my coworker from that night: “Hey, remember that one guy and his mom?”

Thirty minutes later she responded: “FUCK YOU WHYD YOU BRING THAT SHIT UP AGAIN”

“But you remember it, right?”

“Uh I’m carrying that smell to my grave. How’s your week going, stinky oatmeal?”

The weird thing is that we actually do talk about this almost every time we hang out. We get a bloody mary each and order a thing of garlic cheese fries and sit there picking at the gooey stuff, talking about that guy intermittently between gossiping about coworkers and bitching about administration. I don’t know what we hope to unearth about it, or what draws us back, but in some ways our friendship is about that guy. We’re still working on it.

We finished the paracentesis and Dr. Padma retrieved the catheter. In its wake the insertion site continued to ooze copiously. His blood pressure gained by twenty points within thirty minutes, and we started titrating the levophed down. We administered intravenous albumin again, and shortly after that deep wrinkles appeared in his feet as the swelling started to recede.

A short-term fix. We’d just reclaimed his abdomen as a reservoir for extra fluid; he was still weeping internally. But it felt nice, and it gave Maycee some visible indicator of the pt’s improvement.

The charge nurse appeared in the hallway and beckoned to Maycee. “We’re putting in a trach and PEG down the hall,” she said. “You should come see this.” I waved her off and wrapped up the shift while she and the other preceptees crowded around my abd guy’s bed, watching the doctors attempt to open a hole in his neck and one in his belly for breathing and feeding on a long-term ventilator in a care facility.

He’s actually getting… not well, exactly, but better. His hemorrhagic necrotizing pancreatitis seems to have turned around, and while I’m sure he’ll never have full pancreatic function—or, at this point, full neurological function, as he barely responds to questions and commands—he doesn’t look like he’s going to die of this anymore.

At this point, it’ll probably be pneumonia that gets him. That’s what usually gets people on long-term vents.

They did not have much luck with the trach, although the PEG went in easily enough. He just has weird anatomy. It will need to be done surgically.

I barely recognized him when I poked my head in. His hair has grown a lot, and he’s grown a full beard and then had it shaved. The distribution of weight in his face is really different. You can tell, now that the swelling is down, that he’s not a tall man. As they cleaned him up after the trach attempt and let him come back around, his eyes opened and he looked around the room: a human expression of bewilderment, a hint of comprehension, a glimpse… I regret, now, that I hoped he would die. He didn’t seem to be in much pain, despite someone having just literally slit his throat. He looked uncomfortable, but who knows what discomfort and pain mean to him now?

I wonder what his life is going to be like from this point on. I wonder if he’ll ever really wake up. I wonder how much brain damage he sustained during his intense illness, and whether the dialysis and the tube feeding and the tracheostomy will give him some quality of life. It’s entirely possible. It’s also possible that I’ll never know.

When the night nurse came on, he flipped his shit because we had forgotten to change the propofol tubing at 1600. Because propofol is suspended in a lipid solution, we change the tubing every twelve hours to keep it from getting goopy; I had completely forgotten. I didn’t feel like the flipout was completely appropriate, though. He browbeat Maycee when I left the room and told her it was unacceptable to forget to change the tubing, which is a bit much considering that she didn’t know the rules on propofol tubing—it was entirely my fault—and that we were now three hours late on a non-critical task with a pt we’d spent all day struggling to keep alive. Then he cornered her into performing a full bed bath on the pt with him before she left.

Well, part of a bed bath. He’s notorious for this: you give report to him, and he’ll try to keep you until 2030 as his own private CNA, bitching at you the whole time. I hooked Maycee by the elbow, gave the night nurse a frosty look, and dragged my preceptee off to the break room to clock out.

She looked exhausted, excited, ready for a few hours of sleep and another shift tomorrow. She doesn’t even seem upset at the prospect of spending another day in my tutelage.

I think she’ll do well.