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.

2 comments:

  1. I've read through from the beginning to here. I hope with all my heart never to meet anyone like you in their professional capacity, and that, if I must, they are just exactly like you.

    Your writing is uniquely valuable in that you see people, not merely as thoughts, feelings, and beliefs, but as bodies. Often your characters' minds are wholly or partly shut down, but their cells and organs are in furious, purposive activity. You write about the conflicts and struggles of people as bodies. I have very seldom read anything at all like this. Now that I have finished, I hardly know what to read next.

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  2. "Some pts are crafty lil fuckers, I don’t care how confused they are."

    Ooooooooooooooh, Mom's like that. She's even had a psych hold escape from a less secure facility. Not going to name any Kaisers in particular that she escaped from, but she somehow kept her plain clothes in her purse while being admitted (to me this is the tricky part that I don't understand, and probably involves her previous training as a CNA to know how to trick the staff), waited until she was situated in her room and no one was watching, changed back into her plain clothes, and just walked right out. Eventually the police found her walking down the freeway(!). She was trying to go "home," except she was confused as to where she was or which city she had lived in that was "home", etc.

    For what it's worth, she had been down the path of addiction, uncontrolled diabetes, and general medical non-compliance for many many years. I've seen some shit from her that really broke my heart because I couldn't do anything about it. Fortunately she's doing MUCH better now in an assisted living facility with staff to help with compliance, and an understanding that a full bag of tortilla chips is prolly bad for the beetus, to the point that she's liable to go loopy again if she does that too much.

    "voiceless ba ba ba syllables, singing to the ceiling"

    Ho-ly shit. That's EXACTLY what Mom was doing two years ago in the hospital, while not paying me any attention in the slightest. I think seeing her in that condition, in contrast to her baseline, actually screwed me up for a bit.

    Anyway, those lines just got to me since it reminded me of Mom. Carry on. :)

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