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.




She was eighteen. She had given birth four days ago, a healthy baby, and despite having severe pregnancy-induced hypertension during the last few months, she had seemed to be totally in the clear after delivery. PIH and its later stages, pre-eclampsia and eclampsia, are typically resolved by the end of pregnancy as simply as throwing a switch—as far as I understand it, which is honestly not very much. I’m an ICU nurse, with a cardiac focus. I don’t do uteruses.

And I guess I didn’t understand PIH very well, or else nobody informed her PIH it was supposed to resolve with delivery. In the few days since her baby had popped out, the woman had developed heart failure associated with the fluid imbalances of late pregnancy and the massive hypertension of uncontrolled PIH, became fluid overloaded because her damaged heart couldn’t move fluid effectively, and developed pulmonary edema from the backed-up water. On top of that, her hypertension had reached critical levels at the rural hospital, and she had started having seizures.

So she came to us with a magnesium drip to keep her blood pressure low, a propofol drip to keep her sedated, an endotracheal breathing tube so we could mechanically ventilate her, and a foley catheter with the bag filled to bursting as she responded to the diuretics they’d given her. The mag drip, in particular, made me uneasy. We don’t infuse magnesium for hypertension on the ICU, preferring nitroglycerin and other vasodilator drips, but apparently it’s the front-line treatment for PIH.

And it works. A few minutes’ pause on the mag drip while we hooked it up to our own IV pumps, and her blood pressure started to crank up to dangerous levels again. Boluses from the propofol bottle sedated her deeply, but had almost no impact on her blood pressure, which set my teeth on edge because I’m used to being careful with the white stuff lest I bomb my pts’ pressures. (Some facilities don’t allow RNs to bolus propofol at all, for this and several other reasons. It has a bad reputation since Michael Jackson died of it; it lowers seizure thresholds in certain cases, and raises it in other cases; and it’s thick and white and fatty and can raise a pt’s triglycerides very quickly.)

Pausing the propofol drip for transfer, on the other hand, woke her up good and proper. With the mag drip infusing, her blood pressure stayed right in the 130/90 range (a handful-of-salty-chips pressure elevation, nothing to worry us), but she woke up immediately and sat bolt upright in the bed. She rolled her eyes like a panicked horse until the whites flashed, and worked her mouth frantically to try to spit out the breathing tube. This is sort of a recurring nightmare for ICU nurses: we all fear being intubated and not sedated, waking up with the tube in, confused and tied down and struggling to breathe.

It’s not like we don’t have people wide awake and cooperative with the breathing tube in. More than a few pts don’t even get restraints, or we’ll put on soft bracelets with enough slack to just remind them that they shouldn’t grab the tube (but allowing them to write, shift their weight, and scratch their balls at will). But that first waking-up needs to be careful and relatively gentle, to avoid PTSD from the sheer terror of being captive and bound with your airway occupied. And some people have severe anxiety, which is completely fucking understandable, so we keep them knocked out pretty hard until it’s time to pop the tube.

In this woman’s case, she was totally fine when propofol’d out of her mind, but that first waking up was much faster than any of us expected, and it wasn’t terribly gentle. You could see, watching her struggle to focus as we poured the milk of amnesia into her veins, that she had a hundred things to ask us, and no way to communicate any of them.

Of course we reassured her that her baby was fine, that the baby was with the pt’s mother in the waiting room, that the baby was doing well and so was she. It was enough to get her through the next thirty seconds while the propofol put her under. Once she was unconscious, we called for a mother-baby doc and nurse consult, ordered a fresh bag of magnesium, and set to clearing the used linen and tagalong trash from her transfer bed.

I started my assessment. Every pt on the ICU gets a full head-to-toe assessment, every four hours, rain or shine, day or night. It’s become more common recently to let people sleep at night instead of shaking them awake and prodding them until the computer is happy, a practice of which I whole-heartedly approve. But since I work during the day now, I do my assessments like clockwork: on admit, on transfer, and every four hours. Between major assessments we do focused assessments, which emphasize the systems we’re most concerned about. Everything is systematic and very thorough, and since assessment is the nurse’s most powerful tool, we are exceedingly serious about it.

An assessment begins with a general look-over from the door. Is the pt awake or asleep? Breathing hard? Sweating? Grimacing? Agitated, somnolent, pleasantly engaged, crying? My pt was well-sedated at this point, sticky with swift-drying sweat, still tense in the knuckles from the aftermath of awakening. If she were awake, I would progress to the next step: does the pt know her name, the date, where she is and why? Can she follow simple commands, pay attention while I recite a list of letters and squeeze my hand when I say ‘A’? None of this was appropriate for her, and I had already got a pretty good look at her responsiveness to various stimuli. I called her name, and her eyes flickered—good enough for now.

If she were in neurological distress, with a head bleed or a clot-busting drip, I would be assessing her much more closely, with one of a cluster of focused assessment tools. Since she was intubated and sedated, I assessed her with the RASS tool to document her level of awakening, fudged a CAM delirium assessment with a promise to come back and re-assess later once she was through the initial period of sedation, and ticked all the boxes in her GCS tool chart to indicate her responsiveness to various stimuli.

After that, I look at HEENT—head, eyes, ears, nose, throat. Surprise, there’s a tube in there. Welp.

Cardiac: heart rate steady, no weird beats. Listening to her heart with a stethoscope, I heard a third sound between the usual beats, the sound of all the extra fluid in her body interfering with her valves’ closing. Blood pressure fine, as long as the mag’s running.

Respiratory: lungs sound a little crackly from the extra fluid. Swollen all over—even the soles of her feet were ballooned out. (When the swelling goes down later, all of her skin will peel and wrinkle.) Oxygenating just fine, and with the ventilator pushing her breaths in, she’s shedding CO2 pretty well, as evidenced by the end-tidal CO2 being measured by the machine each time she exhales.

Gastrointestinal: a nasogastric tube, clamped, taped to her nose at fifty-six centimeters. Good bowel sounds. Abdomen swollen, but no more than the rest of her body.

Genitourinary: a foley catheter, which I had already emptied twice—a great sign, since fluid overload was her chief issue. As for the reproductive part… I hit that wall in utter confusion. I racked my brain for leftover memories from nursing school: the vaginal discharge would be lochia rubra, a normal presentation; the uterus would be palpable somewhere below the belly button if I pressed on her belly, and should be midline and firm with no mushiness or asymmetry. Fuck if I know how to tell what a uterus feels like at baseline.

Also, her breasts were incredibly distended and painful-looking. I asked her mother, who was sitting with the baby in the waiting room, and she confirmed that the pt had been breastfeeding. “It’s really important to her,” she said. “Is there any way we can, you know, have the baby nurse while she’s unconscious? To keep her from drying up her milk?”

I told her that, honestly, I had no idea, but that I would call the mother-baby center and ask one of their nurse practitioners to consult on her case. Twenty minutes later, the NP showed up, well-dressed and elegantly groomed, with a breast pump and a much-thumbed reference book she used to double-check all of the medications on the pt’s medication list. None of them were a risk to nursing infants. “Just pump her breasts every two to four hours,” she explained to me, “and save the milk in the bottle for the baby to drink.”

Man, if there’s one thing ICU nurses don’t want, it’s ANOTHER task to be performed every two to four hours. Turning pts is time-consuming enough. And yet, I figured life is hard enough for an eighteen-year-old single mother without losing the option of free baby food.

I think I’ve mentioned that I love weird ICU machines—beeping, flashing, pumping monstrosities that take six hours of classroom training to manage effectively, maybe with built-in EKG readings or a touch-screen panel that has to be overridden every hour or so when the pt starts to crater. I am, like many other ICU nurses, a gadget addict.

And yet that breast pump completely defeated me at first. I held it like a live snake covered in human shit, and even after I figured out how to use the flappy valve things to keep a seal and how to hold the funnel parts so that they held the right part of the nipple, I got so freaked out watching the expansion and contraction of the nipples in response to pressure changes—not to mention the needle-thin spouts of white milk spraying into the funnel neck—that I had to take a little break and focus on ordering a new bag of mag.

But as I continued learning to use the breast pump, the weirdest thing happened. I’ve known since I was very small that I wanted to have children, but I’ve also known that I wanted to wait for a while, and I spent most of my twenties in soul-stripping fear that I would become unexpectedly pregnant and have my life, career, and body wrecked before I had a chance to prepare. As the oldest of five kids spread across ten years, a child of a home destroyed by mental illness and religious fear, and a survivor of poverty and neglect brought on by shitty family planning, I have both longed for a healthy family of my own and dreaded the impact of children on my life—and feared that my personal issues will someday ruin my children’s lives.

It’s a strange place to be, psychologically. Lots of conflicting emotions and hopes and regrets, none of which I really know yet how to reconcile. Lots of times where I look at somebody’s new baby on facebook and wonder why I feel absolutely nothing, and lots of times where I look at my best friends’ kid and feel all the chemicals in my body going insane at once.

So as I pumped breast milk and bottled it and passed it to the pt’s mother to feed to the baby, all in a weird fugue state of combined relief—this nightmare of hospitalization and separation from a newborn is not mine to suffer—and envy, that this woman has her child waiting for her when she gets well, and I go home to my husband and my cat.

Kinda fucked up. I do envy my pts sometimes. Some of them have the most beautiful, loving families; some of them are so unreserved and uncomplicated in their desperation for more time with their parents. Some of them have lived amazing lives of travel and action and accomplishment. Some of them are simply happy, despite everything. And sometimes, even with the cancer and the heart failure and the tragedy and the pain, I wish I were them, just to have those things.

But the third time I set up the breast pump, as my pt started to come around from her stupor in response to the decreased load on her heart, I realized she was watching me collect her milk, and made eye contact with her.

“Your baby is doing really well,” I said. “None of your medications are affecting your breast milk, so we’re bringing it to her to drink. You’ll still be able to nurse her when you feel better.”

Her eyebrows relaxed; her head sank back against the pillow. Even propofol hadn’t brought her so much comfort. I thought really hard about that, the next twenty minutes while I finished gathering her baby’s next meal, about being intubated and desperately ill and still hoping for the normalcy and delight of having a baby to feed after recovering.

I was nursing her so that she could nurse her baby.

There are different types of care, even in the ICU. I felt really weird about the whole thing; I was so far outside my element that I hardly understood half the things I was doing. I am not accustomed to performing care by rote, by sheer mechanical direction; I like to know the rationales, the evidence, the best practice methods. Right now, though, there wasn’t time for me to know everything, no opportunity to research further, just a set of half-understood tasks and the necessity of human connection. And the knowledge that, even if I didn’t do everything perfectly and didn’t even understand everything that was happening, I was taking care of my pt as she needed to be cared for.

She might need physical therapy when she stops needing my care. She might have lingering heart failure. She could be working through this shit until her kid is in grade school, who knows? But when she’s done being intubated, which I’m guessing won’t take her more than twenty-four hours, she’ll be ready and able to nurse her baby. Even if everything else is fucked up, that one thing will come out all right.

And, I dunno, I thought a lot about my own hypothetical future offspring, and about what things might be worth the damage I’ll inevitably do. And I think, when the time comes and my husband has finished aircraft maintenance school and we’ve killed off a little of the debt of tuition, when I get my IUD pulled out and start thinking about baby names, I’ll be okay.

(Baby names so far: Alma, Vashti, Enoch, Margaret, Emrys, Sagan, Phillippa, Ra. God I pity my children. My husband proposed Hypatia; I proposed Hatshepsut. We already have a cat named Erasmas, nicknamed Raz, named not for the book-loving philosopher but for the hero of a Neal Stephenson novel that meanders in the middle. Okay, maybe we better not have kids.)
Anyway, after the L&D doc came and examined her—turns out palpating the fundus is just a matter of abdominal massage + knowing what the fuck you’re palpating for—I got an order to take her down for an MRI. This is, in some ways, much like a CT scan, and in other ways nothing like it. For one thing, an MRI doesn’t irradiate you—but it does take forever and it shows different things, depending upon how you apply contrast. Also, you can’t take anything metallic into the MRI chamber or it will get yanked up against the magnet and piss off your MRI techs, just like, so bad.

So we got her ready to take down to MRI. She was starting to really wake up, making eye contact, mouthing words around the tube, at least half of which words were clearly “baby.” I told her, of course, that babies aren’t allowed on the ICU, that it’s dangerous for them to risk being so close to so many gross bugs while their immune systems are still half-baked. And then I got an idea.

If there’s one thing I do well, it’s making sure my pts are clean.

I scrubbed her all over with chlorhexidine. I changed the bed; I took sterilizing bleach wipes to the whole frame. I changed her IV lines to make sure they were sterile. I talked to her mother in the waiting room, and then I scrubbed myself to the elbow and put a sterile drape over her belly. I took her restraints off, trusting her to leave the tube in place and cooperate while I kept her partially awake.

Then I and the respiratory therapist rolled her and her ventilator and her IV pumps out into the hallway, past the nurses’ station, past the entrance to the waiting room. We stopped, and her mother brought her baby and laid her on her chest.

For thirty seconds, she cried and held her baby, her wrist restraints released, her propofol drip paused. The ventilator hissed and squeaked, forcing air into her swollen lungs, keeping her alive against the day she would breathe for herself again. The baby squawked, shuddered, came to rest; she sobbed until the ventilator complained.

Then I gave her another propofol bolus, and she slipped off into a dream, and her mother took the baby and retreated to the waiting room while I loaded her onto the elevator and took her down to the MRI.

The MRI is a challenge. You have to shift the pt onto the narrow stretcher that goes through the scanner, and pack them in tightly—no small trick when your pt is swollen with something like fourteen extra liters of fluid. You also have to get them comfortable enough to chill out while you feed them into a tube the size of your mom’s vagina—roomy enough to admit an adult human body whole, but still tight enough that you wish the whole time there was a little bit of lube.

Also, if you have a drip running, you have to put it in a special MRI IV pump. The pumps are approximately one hundred thousand years old and made without metallic/unshielded electronic components. Plus, when I got to the MRI chamber, the fucking IV pumps were broken.

Yeah. Here I got a pt with a propofol and a mag drip keeping her a) comfortable and b) safe from strokes and seizures, and a chunk of dead plastic that beeps at me impotently like a smoke detector with the battery clandestinely ripped out. (Not that I regularly burn food and have to pull the battery out of my smoke detector. In the mean time, let me give you my recipe for kick-ass ribs.)

(No, for real. Get yourself a rack of pork ribs, rip the parietal membrane off the inside, don’t bother trying to rip the osseous sheathing off the bones even though it kinda sorta attaches to the parietal membrane, sprinkle it with salt and wrap the whole thing in foil, and cook it at 225F for eight hours while you sleep. All the cartilage will melt into gooey gelatin juice and be easily edible instead of chewy and gross, and the runoff can be stirred into your favorite BBQ sauce and brushed over the ribs, then broiled at 500F until it turns into a crackly, sticky mess. You can eat the bones, if you cook it for more than eight hours—they decalcify and just dissolve in your mouth. This shit is so good you don’t even know. Just put a foil-lined pan underneath, or your oven floor will fill up with drippings and smoke like a Frenchman until you clean it two weeks later like the gross slob nurse you are. Not that I would do this.)

I considered, for a moment, just pausing the drip. She’d stayed calm long enough to hold her baby; maybe she could hold still long enough to handle the MRI? Maybe. Not really. I paused both and within minutes her blood pressure skyrocketed and her eyes rolled in distress.

So I did a thing I trained to do in nursing school, the semester before I learned about vaginas and all the horrible things that happen to them when a ten-pound human rips through them. I did dimensional analysis.

I pulled out my phone, out in the MRI tech room by all the computers where you can get as close to your pt as possible without magnetically bricking your portable internet machine. I did, I swear to sweet tiny Jesus the baby, suckling at his mother’s breast, math.

So there ya go. Where will you use this stuff after high school? You’ll use it here, with an eighteen-year-old mother gasping on a stretcher, with two sterile syringes Y-lined into your IV drips, drawing from the bag and pushing one milliliter at a time, counting seconds for two hours while you push proprofol and magnesium at pre-calculated rates to keep her blood pressure stable and her terror at bay.

You’ll use it one tiny push at a time, while the seconds stretch to minutes, while you remember that the surest way to make time drag is to watch the clock. You’ll use it while the MRI bangs and shrieks through your earplugs, with your head rested up against the plastic so you can reach the IV and your back twisted so your arms can twist further, with your fingers tingling under the magnetic field where they cross and the iron in your blood forms a bridge for the invisible force of technology to meet and reinforce itself. You’ll use it until your foot goes numb and you can’t hear, and the thing that keeps you upright is the sound of your pt breathing through a plastic tube and the thought of her baby, waiting for the next bottle of milk, the shadow and image of the children you may yet have yourself if you ever get over your nightmares and your memories and let them have a chance to survive your slipshod parenting, the way you survived yours.

When I pulled her out of that passage, calm and quiet with a blood pressure that wouldn’t offend tissue paper, I felt like I was the one giving birth, being born. Maybe that’s a bit cheesy. We do, though, envy our pts from time to time. And we do have hope for things beyond the ICU, for ourselves and for our pts, and for the people who we will never see on the ICU, who will escape it by inches or miles and live their lives ignorant of the breathing tube and the propofol drip.

And when I brought her upstairs, I might have missed my lunch and both of my breaks (which is a fucking big deal, okay, I’m lazy as fuck and I always get my breaks), but despite the uncertainty of mother-baby nursing and the exhaustion of MRI pump-impostership and the weirdness in my own brain, but I felt like my pt had given me something I could never have given her. I am indebted to her; does that make sense? I hope I was able to pay her back. (The next day she was extubated, transferred to a medical floor, and allowed to nurse her baby. She went home later that week. She was absolutely, totally fine, except for needing a while for her heart to recover. She was all right.)

Also, during this shift, a transport team showed up from an long-term acute care center, and they picked up my abdomen guy from so long ago. They took him away to be cared for somewhere else. He waved his hand at me and two other nurses as he left. He’s not himself, not exactly; but there’s some of him left, and who knows what else he’ll gain in time? Maybe we saved something. I hope he does well. I will miss him.

We don’t always have good outcomes. But I don’t feel too bad about these two.


(Even if I made them both, embarrassingly, all about me. Well, I’m a selfish person. I’ll just deal with it later, when I wake up tomorrow and go to work, wishing I’d slept instead of writing.)

13 comments:

  1. A big part of why I am reading these stories, is about meeting the person behind the nurse, i. e. you. Ive had the opposite of a good an competent hospital expierence, and reading your stories assures me that I was the exception to the rule...
    One part of your humanity comes through in your framing, your way of telling a story and your language...
    But another side comes through when you make sidebar remarks and tell anecdotes. Both round out and complete the fictional image of you as a nurse, so dont chastise yourself, or hold back on interveawing the more personal stuff where it comes naturally....Atleast not on my account.

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  2. That is the first rib recipe I've ever read that included the phrase "parietal membrane".

    Anyone can recite Tales From My Fascinating Workplace. A couple of people can even do it with a florid playfulness that lets you see and hear and smell the place whether you want to or not, and if I just close my eyes while reading it I can picture absolutely nothing because this is a written story and I need my eyes open to read it. Your writing is special because you tell us how you're feeling and what you're thinking in a way that helps us put ourselves right there in the story. Sharing the emotional part of the ride has a kind of visceral excitement that you just can't get from reading someone's otherwise captivating recitation of exactly what went where.

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  3. I'm really hungry for ribs now.

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  4. Well god dammit, you made me cry.

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  5. Welp, I shouldn't have read this at work. I had to take a break to finish it in the silent break room where I could tear up in peace.

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  6. I don't want children, for a lot of the reasons you don't, although not nearly as severe. I have a crippling fear of the damage I would do. But I think that in some ways that damage makes us better parents. We live in fear of the mistakes we might make so we try harder to avoid them. You're going to do just fine being a mother, Elise. Working on the ICU keeps you human, it keeps you in touch with the gentler side of you - it wasn't destroyed by your childhood. You're going to be just fine.

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  9. I had pre-e. It got caught before things got bad, but this could have been me.

    And I can relate 100% to how relieved that mom felt when you told her what you were doing. My daughter and I were separated for 24 hours (me in recovery on the mag, she in the NICU with low blood sugar), and I was going batshit crazy the whole time.

    We're all good now (she's 2.5, I'm dumb enough to be trying again), but I will say it was awesome nurses who mainly got me through that experience. So thanks.

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  10. One of the big reasons I had my hysterectomy is because I am too scared to have kids, for somewhat similar reasons. My brother just had micro-preemie twins and while I don't want the surviving one to die, I also am terrified for what living with my family's baggage might bring her.

    That ribs recipe sounds bomb af. I might make it over the course of a day so I can check on things in case of smoky splatters.

    You did an amazing job in the MRI sitch. That was really impressive.

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  11. We miss your posts, Elise! I know I do, and what I've read confirms my belief that others do, too. You write well and movingly, and I hope you will resume this writing. For what you've done, thanks! For what I hope we are about to receive, thanks!

    Mike

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  13. This was really beautiful. I know the relief she felt when she heard her baby was okay from personal experience. And I love that you took her desire to breastfeed so seriously. Your writing is just so evocative. I'm in awe.

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