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.




Brain-case bleeds are typically classified by where the bleed occurs in relation to the different membranes that cover your brain. Different types of vessels run at different membrane levels; the epidural space, outside the dura mater (epi = on, dura = the specific membrane), has arteries, so bleeds out there are quick and high-pressure and extremely painful and exceedingly dramatic. The subarachnoid space, between the arachnoid membrane and the pia mater, is where ruptured aneurysms bleed into, so you can imagine that a subarachnoid hemorrhage is hard to ignore.

But the area just under the dura mater, the subdural space, is largely venous, so bleeds there are low-pressure and typically happen because of trauma. You knock your head and it hurts, sure, but after the initial tissue trauma stops being painful you think everything’s fine. Meanwhile, there’s nothing to put pressure on that venous bleed inside your skull, so it just oozes and oozes until it’s slowly blown up a giant blood blister inside your skull and crushed your brain. Hours can pass before this happens—long enough for you to imagine that the nausea and dizziness aren’t related to your skull smacking against the fridge door when you fell. Long enough for you to take two aspirin (a blood thinner!) and go to bed.

We’re not sure how long this lady was bleeding into her brain before her family found her.ShHe was tucked nicely into bed with a bruise around her right ear, totally unresponsive but still breathing and maintaining her heartbeat on her own. She was brought to us in an ambulance, and the neurosurgeons immediately hauled her down to the OR, performed a craniotomy to drain out the blood, and sent her up to the ICU to see if she’d get any of her brain function back.

That was yesterday. Today she’s not really doing much of anything. She’s getting pain medication through an IV drip, but no other sedation, because we really want her to wake up. She takes a lot of pain medication at home for an old back injury, and since she’s post-surgical, we don’t want to give her no pain control, or she’ll have to deal with a cut-up skull and a bad case of opioid withdrawal all at once.

Yes, your body can go into withdrawals while you’re unconscious. Your body can even experience pain and other warning signals while you’re totally out of it, and react locally and systemically. Doctors who place arterial lines on deeply sedated pts often deaden the area with lidocaine before inserting the line, not because the pt might wake up from their induced coma and yank their hand out of the way, but because the artery might spasm as it’s stabbed with the needle, and it’s hard to advance a line into an artery that’s clenched down in pain.

This was visible with my pt in that, when we paused her low-dose fentanyl drip, her blood pressure skyrocketed. Even though she didn’t flinch when we brushed her corneas with a tuft of cotton, her body was still able to interpret what had happened to it as Very Bad and was reacting accordingly.

On top of the craniotomy, she had two other problems. One, she had (of course, and you probably expect this by now) vomited after becoming unconscious and inhaled some of it, so her lungs were starting to look ARDSy; two, she had developed rhabdomyolysis during her period of total immobility, and her kidneys were clogged with dead chunks of broken-down muscle.

I’ve mentioned that it takes very little time for the body to lose mobility if it’s not exercising. It also takes very little time, all things considered, for your muscles to start to decay if you lie around motionless. Dead muscle chunks rip free and float in your blood, clogging up in your kidneys and poisoning your whole body bit by bit. This is called rhabdomyolysis. It can also occur with extreme overuse of muscles—I had very mild rhabdo once after my first time ever snorkeling, because I was desperately out of shape and swam around paddling all day even though my legs hurt, and I ended up with tan pee and painful kidneys and a full day of lying in bed crying over my destroyed calves, followed by a doctor being extremely stern with me. Trauma and crushing injuries, electrocution, and chemical destruction of cells can all cause rhabdo as well.

Of course, working on the ICU, most of the rhabdo I see is secondary to either CrossFit-style over-workouts or to immobility after a pt has a stroke or a bleed. They come in with kidney failure from the clogging, nitrous waste toxic buildup pickling their brains, gross brown piss from all the myoglobin spilled out of broken muscle cells, and often intense muscle cramping if their muscles ever get any function back.

Anyway, it being a full 24 hours or more since this woman’s brain was decompressed, with the beginnings of ARDS puffing up her lungs and her kidneys ravaged by rhabdo, her chances of surviving are miniscule, and almost nothing if one counts quality of life. Her family is loving and supportive, but really struggling with the onset of grief—they think that loss is still a possible future, a fate that might yet be averted, rather than a thing that has already happened while they were sleeping two nights ago. Even if she doesn’t die of this, she will never be the same person. Her CT scans show diffuse white patches in her brain, indicating brain edema, which in turn betrays dead brain tissue.

Her thighs have blistered up where she was incontinent that night. Over the course of the shift the blisters ballooned, then popped, then oozed. We put in a consult to Wound Care, slathered the sites in antibiotic ointment, and covered them with non-stick foam dressings. These foam dressings—padded, slippery, clingy rather than adhesive—are a mainstay of the hospital; every pt who is transferred to the ICU gets one put on their butt first thing, barring only pts in good enough shape that they wear their own pants, and pts who are shitting too hard to keep anything within blast range of their sphincters. It seems ridiculous, but the padding and friction relief protect skinny, protruding tailbones almost as well as proper butt flesh.

And speaking of shitting… our lady suffered from chronic constipation, and a few doses of stool softeners unlocked her guts beautifully, filling the bed with everything she hadn’t been able to poop in god knows how long. It was an uncommonly aromatic buttflood; people complained to the first-floor ER desk about a foul smell in the elevators that serviced our third-floor lobby. Anne, to her credit, didn’t complain at all as we cleaned and mopped and contained the flood, even though the stench was incredible.

We learned about soap-and-water bed baths. We learned a lot about them. You can only get somebody so clean with wet wipes; eventually, you have to switch to a nice soapy tub of warm water and a handful of towels.

Some of my coworkers don’t believe in soap-and-water baths, for some reason I will never understand. If my pt has crusted-on shit stuck to their butt hair, I’m not going to waste four packs of wet wipes before I start running the sink. Mavi, on the other hand, will wipe until shift change, examining each wipe for diluted shit streaks and chanting: “No yellow! No yellow!”

I think the idea is that there’s no risk of the wipes being dipped back into the soapy water, contaminating everything you wash from that point on. But come on, dude, just don’t double dip.

After that we sat in the hall for a bit, shell-shocked, and pretended to chart while staring into space in various directions. The intensivist dropped by and asked us what we were doing, and I said I was mustering the energy to walk up to the front nurses’ station, so he grabbed the back of my rolling chair and pushed me up the hallway, mock-scolding me the whole way about laziness and entitlement while gently bashing me into every piece of equipment on the way. I laughed until I nearly puked. Then I picked up a potassium replacement from the tube station, where the pharmacy sends all the medications up that don’t fit in the med cabinet, plopped my butt back in the chair, and superciliously snapped my fingers at the intensivist for a ride back.

He just kicked the chair’s rolling base and sent me spinning about ten feet down the hallway, then chased me down the hallway to show me an iphone picture of the sushi he had for dinner last night. He is that kind of intensivist: dramatic, hardworking, willing to jump in and help, humorous, and capable of snapping your head off if you fuck something up. He’s a bit of a diva. Of course we all adore him for it.

His unusually high energy levels were explained shortly after that: he was getting all psyched up to put a pt in the rotoprone bed. He loves rotoprone beds as much as I do, for what I’m assuming are similar reasons, and when we have a pt in a roto he basically moves into the workstation outside their room and can’t be dislodged for love, money, or premium sushi.

I love rotoprones because they are huge, complicated, labor-intensive, bizarre to look at, incredibly effective, and accompanied by a host of other techniques and medications that keep you hopping all day. Rotoprones are, essentially, giant padded beds into which a person can be packed, then rotated face down and cradled in the packing cushions while the bed rocks them back and forth to allow their lungs to drain. It is incredibly effective at supporting pts through the ravages of ARDS, although it really needs to be initiated early in the ARDS process to have its full effect.

In the rotoprone, for instance, pts need to be pharmaceutically paralyzed. This requires us to shock their wrist nerves gently at various intervals to ensure that they’re paralyzed enough to prevent oxygen-gobbling, but invisible, processes like shivering. We want them to be able to twitch a little, but not a lot, so while we’re adjusting the paralytic drip and watching their adrenal glands for signs of deficiency (a paralytic side effect), we’re also zapping them with a little box and writing down the results.

There will be inhaled epoprostenol to reduce the high-pressure imbalance in ARDSy lungs; maybe a Lasix drip to drain off excess fluid; high doses of sedatives and pain control medications; almost certainly pressors, which must be adjusted constantly in real time. Insulin and sugar must be balanced precisely. Electrolytes skew wildly in every direction, and must be corrected. Careful skin maintenance is required to prevent pts from developing pressure ulcers on their faces or having their nipples scraped off by the endless rocking; rectal tubes and foley catheters drain waste to keep it from sloshing into the bed; the angle, speed, and Z-axis tilt of the bed must all be adjusted constantly to drain vulnerable areas of lung and then return the burden of oxygenation to less-vulnerable areas when things start to destabilize.

It’s an incredibly complicated and fascinating piece of equipment. It would have been really neat to orient Anne to it, and let her try out her new ICU chops on something that complicated and crazy. But we already had our cranie lady, so we helped move the roto pt into their new bed, then returned to our own caretaking.

The family watched her lying there with drawn, distant faces, no longer searching her face for any flicker of life. They had been holding her hands and chatting about happy memories; now they sat on the couch in the corner and sagged against each other like empty pillowcases, grim and gray and exhausted.

They were realizing, of course, that she won’t come back. It’s an awful thing to face. It can only be fought off for so long, and when it catches up to you, it’s like suddenly realizing that you haven’t slept in years and all the happy things you thought you remembered were just hallucinations brought on by lack of sleep.

It’s not always this way. Sometimes, even after people start to realize that something is gravely wrong, their loved one recovers at least some measure of their prior function. The truth is that it’s very, very hard to assess someone’s prognosis in that first forty-eight hours, because the injury isn’t yet complete, and we can’t tell when the recovery really begins. It takes patience, at a time when all you want to do is intervene and save their life. It tempts even neurosurgeons to unfounded optimism and pessimism, to superstition and MRI augury.

But the injured brain is a locked room with no windows, and all of its identical doors lead to different places; and time is medicine, and hope and grief are each their own excuse for being.

A little before shift change I went into the break room and caught the intensivist watching Fox News and heckling through a mouthful of instant oatmeal. “My husband and I are going to overthrow society and shit on the Bible,” he goaded the newscaster. “And when you get sick you won’t care because I control the antibiotics!” I backed out of the room without comment. I’ve seen a lot of people come onto the ICU, especially in Texas, and try to dictate which races and ethnicities and sexual orientations are allowed to take care of them. I’ve noticed that, as their condition degenerates, they stop giving quite so much of a shit. It’s hard to keep up a good bigoty froth when you can’t fucking breathe.

Anyway. I heard today that Martha’s family declined the autopsy, which I fully understand, because all medical signs point to her having died of a pulmonary embolism. A clot most likely formed in her arm or her leg and then migrated into her lung, cutting off blood circulation to her air supply—her increasing irritability overnight, the suddenness of her demise, her recent history of dehydration and broken bones, and her PEA arrest all point to the likelihood of this. And, honestly, given that she was on the ICU under constant monitoring when she died, there is nothing else we could have done to prevent it.

Sometimes people just, you know, die. Sometimes even the ICU can’t save them.

________________


I think, after this week, that I’m going to take a week or two off while I recalibrate my goals and try to make them realistic. I hadn’t realized, starting out, that this blog would quickly result in my writing hundreds of thousands of words about my life, or that I would start to feel burnout only a few months in. As it stands, I haven’t had time to pursue things like podcasts, pathophysiology posts, responses to comments, or even dumb nattering in my common internet hangout spots. I would like to see about making a book out of this blog, which would require time for editing and rewriting and creation of new material; I am also working all of the shifts I write about, often back to back, often more than three per week.

So I will post tonight, then Friday night, and then I will take a week off of regular posts and see if I can wrangle a more realistic schedule and set of goals that will keep the good stuff coming without draining my writing reservoirs dry.

It really helps that you guys are so supportive and wonderful, and that feedback has been so constructive in both positive and negative ways. I feel like I’m just starting to develop as a writer, and keeping this blog has shown me a lot of areas in which my medical knowledge is frankly in need of growth. It’s also encouraged me to dedicate myself more fully to compassion and empathy in my pt care, knowing that I am holding myself even more tightly accountable than ever before.

This has, so far, been an incredibly encouraging experience, and I hope I can find ways to keep it rolling for a long time yet.

9 comments:

  1. Glad you saw this coming early and I hope you take all the time you need! Too many decent writers of good subject simply disappear. I'm sure all the readers will still be here. :)

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  2. Just checking in to say I'm really enjoying this, and looking forward (?) to that guy with the cats story.

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  3. Take the time that you need to get things done, even if (sadly) that means rolling things back a little. Though we all love hearing about your shifts and learning new things, even a few tweets would be better than having you get frustrated and vanish. Is @elise_the_great you?

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  4. I love reading this blog and it is absolutely amazing to have a window into your world like this. I and others continue to be beyond impressed that you've managed to keep up the tempo of posts that you have, and to be honest I'm astonished that you have the time and energy - nobody who has an opinion worth paying attention to is going to get upset at you for taking a step back.

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  5. A friend linked me here last week, right before one of our big Infection and Immunology tests (PA school). My reward for passing that test was getting to binge read your entire blog.
    Take the time you need to regroup and come back with a sustainable posting schedule! I love your writing and hope to be able to enjoy it for a long time yet.

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  6. It's been a long time since I've checked a blog religiously to see if it's updated. I've been on the blog writing/maintenance burnout train myself, so it's good you're self-aware about the dangers. Do what you need to do to keep your writing pace sustainable, because this is some phenomenal stuff.

    Also, for real, really want to read about the dude, his mom, and the cats.

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  7. I have a small publishing house and I would LOVE to see you do a full length book, you're an amazing writer. Feel free to mail me if you're curious about what it entails... shannon@ cooperativepress dot com

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  8. You sound like a great nurse and a great teacher, and you're definitely a helluva storyteller! It's been a great ride so far, but don't burn out! Hope to hear more stories when you are ready.

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  9. You describe my life perfectly. I frequently take care of dead patients. The feet are dead first, then the hands, etc. People in their 90's who would not possibly want this, if they had a say in it...but that ship has sailed. Burnout, yes. It is hard to keep a cheerful heart if you care about people.

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