Let’s just get this out of the way: I’m weird about hugging. I’m not the type to have anxiety attacks when someone invades my space, although I know plenty of people who are. I just grew up in Texas. The sheer number of people who’ve armpitted me in Wal-Mart on the grounds that our grandparents used to go to the same hairdresser…
And while we’re admitting things, I’ll get this off my chest: I think pts are gross. Their families are gross. I, while I’m inside the hospital, am gross. Literally everything and everyone within a block of my job is disgusting and I generally assume that anything touching me while I’m at work is probably covered in a thick fondant of shit and dead roaches.
It might be a little dysfunctional, but this is just how my brain works. It helps me keep track of who’s touching me and how much shit I have on my body at any given time.
So you can imagine how delighted I was when I introduced myself to my pt and her daughter and was immediately greeted with a full-frontal hug.
The pt was unremarkable. Here for CHF and a bad case of being seventy, she needed a few rounds of diuretic and an adjustment to her water-pill dosage at home. She was exceedingly friendly and liked to chat, and her fifty-something year-old daughter was even more friendly but preferred to express it by hugging people. Unexpectedly. Repeatedly.
I laughed it off the first time and gently informed her that we don’t hug in the hospital because we don’t want to transmit germs. The second time, I kept it short and sweet: “No hugs, please!” Both times she apologized generously and assured me it wouldn’t happen again, she was just so glad her mother was getting such wonderful care, we were all so kind and loving etc. Tears glistened in the crevices of her eyes. The smell of her clothing lingered like a fart in a warm room: cat dander, mildew, decaying plywood. I could picture their house very clearly.
The third time, I walked into the room and started washing my hands at the sink, keeping an eye on her as she approached. Surely she wouldn’t— oh yes she would. Lip trembling, she came at me with both arms outflung. “No, no no no,” I said, not quite managing to drown out the noise she was making: I know, I know, I’m just so glad—
She embraced me like a plastic bag strangling a sea turtle. Her right forearm crushed my left jugular. Her hair pressed against my face, crown to cheek, smelling like stale talcum and unwashed scalp. “I knoooooow,” she crooned, nestling her torso against my arm so tightly that I could feel her underwires cutting into my bicep.
So I stuck my thumb in her ear.
I mean, I really got it down in there, wiggled it right up in the ear canal, still wet from the sink. I wish I could have taken a picture of her face as she drew back: the dawning horror, the nauseated sense of violation, the outrage and confusion and betrayal. She opened her mouth to protest, and nothing came out.
“Oh, I figured we were at that level,” I said. “Since we’re hugging and all.” She didn’t reply; she just retreated to the chair in the corner, where she sat watching me push furosemide with wide accusing eyes. At that point, I guess, she was kind of working under the assumption that I am genuinely unhinged and might do anything imaginable at any time. She wasn’t exactly wrong.
She went home ten minutes later, without hugging me again.
I found black cat hairs on my scrubs for the next hour. My cat is peach-colored. I shuddered as I picked each hair off, even knowing that if I met a long-haired black cat face-to-face I would probably pet it and headbutt it and make revolting noises of affection and taunting until it got fed up and cut me, which I would deserve. The same way that woman deserved a mega wet willy.
That was the last interesting thing to happen with that pt all shift. I discharged her around 1300 and her son came to get her.
My other pt was a heavyset woman, bedbound at home and cared for by her beleaguered family, who had started vomiting three days ago and was diagnosed with a major UTI upon admission. I would also have diagnosed her with severe yeast-itis of the crotchal region, if I were able to diagnose my pts.
Not that this was unexpected. Any time your family members double as your sole caregivers, you stand a pretty high chance of not getting the care you need. It’s not that family members like to neglect their loved ones, it’s just…
Well, okay, look at it this way. I work twelve-hour shifts. I work three of those per week, and have four days off, unless I pick up some overtime. I hit the end of an average work week so tired I can barely see straight, with girdling lines on my ankles because I have to wear compression stockings to prevent swelling, with a deep muscular ache in my back and a wire-tight knot between my shoulderblades. My eyes sting; my head throbs; my mind is too splintered to focus.
On days when census is low and I end up taking care of pts who don’t need critical intervention, who only need to get up to the restroom and back into their chairs, who need to be fed and wiped and turned and given meds, I am more exhausted. A good shift, one that doesn’t leave me too tired to cook dinner, is one where my pt is bleeding from every orifice and ricocheting through a range of blood pressures from “firehose” to “wet fart.” A rough shift, one that sees me pulling over on the way home to nap for twenty minutes, is one where I’m caring for pts who just need wound care, incontinence care, dysphagia feeding, a nice bed bath…
Mind you, I’m taking care of maybe three pts, whereas a family member providing full-time care will be one-to-one. I can call for help if I need it, though, and I end up needing assistance once every couple of hours with each pt. I can give meds to calm my pts if they’re agitated and angry. They generally don’t know me well enough to try and get under my skin when they feel testy. I don’t have to take them to any appointments, or cook them meals, or buy them groceries, or pay their bills.
At the end of my twelve hours, I can go home. Thirty minutes after I swipe my badge, I’m eating pad thai on the couch, watching West Wing again, trying to coax my husband into giving me a foot massage. I don’t have to worry about most of them, at least until I get them back the next day, and eventually they’ll be discharged from my care to someone else’s. (Okay, some of them stick around forever… and some come back a hundred times. But that’s still considered unusually burdensome to staff.)
If you’re one of three caregivers taking care of Grandma, you’re going to spend about a third of your time taking care of her. Maybe more—it takes a lot of man-hourage to keep someone who has major health issues alive and relatively well. I mean, imagine how much time and work it takes to keep your own damn self alive and well, and then consider that you’re probably a lot more mobile and able than an eighty-year-old woman with dementia and diabetes. Point is, some shit’s gonna slide through the cracks.
If you’re one of two caregivers, you aren’t going to make it long without either turning into a gray-faced ghost with bony fingers, or turning into a complete lunatic who hugs nurses without warning. If you’re the only caregiver, your loved one is going to turn into a heap of yeast and sores, and there’s just no way you can deal with it. And this is assuming that you have enough caregiver training to know what you’re doing and why turns are important.
Point is, this woman was here because her husband and two children were doing their best to take care of her at home, which meant she wasn’t getting good quality care. She had several bedsores, probably needed her meds adjusted months ago, smelled like stale piss, and was so yeast-eaten that wiping her vulva removed a sheet of colonial microbes and sloughed-off, half-eaten skin. Beneath that was red, raw flesh.
I wish I could tell you that this was the worst case of yeast-eaten skin I’ve ever seen. Sadly, you know it’s not. A few years ago, at a different facility where I worked nights, I admitted a pt named Mrs. Beaumont* who was found down with a stroke.
Imagine, if you will, that you are a big lady. A really big lady in her seventies. Your husband is a mustachioed beanpole of an old man who wears tweed jackets with elbow patches, and can barely lift his bow-tie to put it on before heading out to the park for some chess.
Now imagine that you fall out of your chair one day and can't get yourself back on your feet. Even your husband's help isn't quite enough. What do you do?
...If you said anything besides stay on the floor for six months, you will probably understand the sublime horror with which I began that nightmare admission.
("She's very stubborn," said her husband. "She thought it would be embarrassing. She wouldn't let me get help." Well jeeze, man, what was she gonna do? Come after you?)
The smell arrived about fifteen seconds before she did: a yeasty, creamy, purulent smell like a raw chicken breast left in somebody's vagina to rot. Between her abdominal folds, in her armpits, under her breasts, and in the creases behind her knees, yeast infections had grown with such blithe abandon that they resembled melted mozzarella, and had flayed the skin beneath down to the subcutaneous fat. Her scalp was matted with a cradle-cap fungal crust a quarter-inch thick, which shattered as we palpated it; beneath it, the scalp bled freely. Her fingernails were grown out longer than her actual fingers, yellowed and crusted with fecal material and other, cheesier substances... and curling tendrils of overgrown quick-skin pigtailed out from the filth. The shit that smeared all over her body was almost an afterthought.
Her husband had come home from work (by the EMT's accounts, the house was an unlivable sty of food-refuse and pissbottles) to find her... less responsive than usual. Totally unarousable, in fact, and covered in vomit. So he did what any normal person would do: he went to Walgreen's, on foot, to buy her some Tylenol. When he returned, he found her further befouled with her own feces, and seizing, whereupon he finally called 911. Diagnosis: a series of strokes, including one in the pons.
A stroke in the pons—the crown of the brainstem—is one of the worst things that can happen to your nervous system. As the damaged tissue finishes dying, you lose basic life functions like breathing and maintaining equilibrium. The stroke was potentially devastating enough that, even without knowing if she was still inside the 90-minute window to effectively receive clot-busting drugs, we loaded her with tPA and crossed her fingers.
After all, she had multiple strokes. It was entirely possible that some of the strokes were older, and the pons stroke was fresh. And while tPA is a dangerous drug—it’s made of strep toxin and melts clot-matter on contact—it was likely her only hope.
We assumed, starting out, that she’d developed a deep-vein clot in one of her legs. They were tremendously swollen, and lying in one place for six months puts you at astronomic risk for clotting, so we called in the ultrasound tech to check out her legs for big chunks of cemented blood.
Before that, though, we had to start cleaning her. This was a strange process; the horrors we expected were absent, replaced with other awful things we didn’t anticipate. Her husband clearly gave her the most devoted care an untrained civilian in his eighties could manage. She had no pressure ulcers, a near impossibility for patients bedridden for six months with severe obesity; her nutritional status was quite acceptable; her peri-anal area was fresh as a daisy, suggesting that he cleaned her nether bits thoroughly after each toileting, even though her massive pubic apron lapped over a graveyard of yeast. The shit smeared all over her body was all relatively fresh. He had really worked hard on her. He just, you know, let her lie on the floor for six months without calling for help.
And apparently the devoted care that kept her grundle squeaky-clean was not applied to any other part of her body. The yeast just… ate through her skin, gnawing so deeply into her abdominal folds that the wounds tunneled, stripping the skin under her breasts until bubbly yellow fat was visible when we washed the goop away.
You’ve probably figured out by now that I have intense feelings about keeping my pts clean. That first shift, I bathed her over and over, wiping and soaking and soaping and scrubbing. I got all the shit and most of the yeast by the time I clocked out.
Over the next few shifts in a row, I got her clean. I soaked, scrubbed, cut, and filed her nails, trimming away the snake-tongue overgrowth of quick-skin with a lot of shuddering and stopping to breathe. I didn’t know the skin under your fingernails could grow out like that; admittedly, I keep my fingernails trimmed to the quick and meticulously hedged for hangnails, because I hate having fingernails at all. They make handy little tools, sure, but they make you pay for it in collected dirt and germs, torn skin edges, and snaggled corners that catch and tear. My fingernails are fairly inoffensive—I don’t even have semilunes—but they still annoy me regularly, and the thought of thick yellow shit-crusted hag-talons with chewy curls of quick-skin peeking out from beneath… well, now you know what it takes to gross me out.
I also washed her hair, what remained of it. We have shampoo caps on the ICU, which are just shower caps full of dry shampoo and leave-in conditioner that you can massage into someone’s gnarly tangles, but this lady got the full barber’s wash. I shoved a flat bedpan under her head, grabbed a bottle of antifungal shampoo, and spread towels everywhere. Then I drenched and shampooed and massaged and rinsed, and repeated every few hours every shift until the yeast crust was completely gone and her scalp was healing under a peppery layer of gravelly scabs.
The yeast goo I replaced with vast drifts of antifungal powder. The crusts of overgrown skin on her toes and heels softened up and sloughed away under a relentless onslaught of petroleum jelly and intermittent scrubbing. She started to look like a human again.
Of course, none of this could save her. The tPA hadn’t helped. One shift, her right pupil blew open and fixed, indicating that the massive vascular injuries that cascaded into the original stroke were still truckin' along, happily fucking up whatever brain function she had left. She had a couple of small clots in her legs and one in her arm, but nothing you’d expect to end with a shower of strokes.
Her husband really struggled psychologically with her illness. He was almost pathologically terrified of her, even now as she lay in bed perfectly still and dying. He panicked when I cut her nails, because she might not like it; he left us notes all over the room reminding us not to tell her he’d called the medics. I suspected that their relationship was one of catastrophic emotional abuse and physical enabling. Additionally, we discovered three days into her hospitalization that she entertained herself in her (quite literal) downtime with a laptop, where she chatted with all sorts of people from all over the world.
One of them actually showed up. I’m not certain he was a preacher, but he was from South Carolina, he was about forty years old, he quoted scripture constantly, and he had a pompadour. He was actually quite handsome if he kept his mouth shut—I find plantation accents and Bible verses equally boner-killing—and he drove us all completely bazonkers with his caterwauling, “affirming,” and demands.
He stayed at her bedside for about four days. It wasn’t a good visit for him. On the first day he was wearing a crisp powder-blue collared shirt with a crown embroidered on the pocket; on the third day he was wearing the same shirt with stains under the arms, and his hair was beginning to go rancid. He couldn’t find a hotel room, because there was a major game in town or some such, and as often as he yelled into his cellphone that “money was no object,” he couldn’t find a place to stay that wasn't the Beaumonts' horrifyingly filthy abode. So while Mrs. Beaumont's husband went home and slept in familiar squalor for four days, the preacher slept in the waiting room, and despite his eye-rolling behavior, we kept him in blankets and pillows and terrible hospital coffee until he finally gave up and went home.
He was convinced that we were killing her, that we had given her the infection that caused the inflammation that… uh… that caused the strokes that landed her in the hospital? I’m not really sure how that worked. A few days after he went home, Mrs. Beaumont also left us, overcome by her raging yeast infection.
No, not a vaginal yeast infection (although I’m sure she had a bit of that too). A blood yeast infection. They had eaten their way into her vasculature through her skin, and wandered free in her blood—which was, no doubt, sweeter than it should have been, since her diabetes was poorly controlled. They had, it seemed, formed colonies in the dark rivers of her arteries, and grown there in peace and prosperity until chunks of them broke away and floated free in search of new places to live.
Chunks of yeast, floating free. Yes, it looked like the fatal strokes were caused by septic yeast emboli, not by blood clots. Her brain was choked by wandering blobs of fungus. They ate her, and then they killed her.
It’s strange to think that, when they buried her, she was still filled with yeast. They must have continued their feast for weeks in the grave, happily consuming until she was completely gone.
Nowadays, of course, I work the day shift, and my time is consumed with physicians and procedures and other daylight nursing shenanigans. I don’t have time to wash, soak, dry, and polish my pts like I’m detailing the popemobile. I still do a lot of scrubbing, though, because old habits die hard, and because sometimes I wish I could go back to the weird world of nights.
Especially since you can throw your pts’ families out if they’re too weird to handle, and chances are good even your most awful pts will sleep for at least a few hours. I’m better now at handling crazy than I used to be, but it’s still not fun, and sometimes I desperately try to talk my pts into “taking a nice nap” so I can close the room door and hide from them for a while. Sleep deprivation on the ICU is a very real problem. Pts and their families harassing and verbally abusing nurses… also a very real problem.
A few weeks after Mrs. Beaumont died, I started a shift with a charming gentleman the previous nurse described as a 'nasty, racist, foul-mouthed old coot, oriented times three.' Score. I walked into the room already disgruntled, and I got this as a greeting:
"Shit, another one? Can't you fat cunts leave me alone for thirty minutes?"
Okay, I try really hard to be nice, but even I have limits. I replied: "Did you just call me a fat cunt?"
I don't think he expected me to say The Word. "Well, not you specifically," he muttered, but in the week before that I’d had a three-day organ procurement prep with a 23-year-old return patient who left AMA after her open heart and shot up with god knows what and fucked her brain to a bleeding pulp; I'd attended her procurement surgery, watched her organs be declared useless, and driven home still smelling her blood; I'd gone to the deathbed of a coworker's son, my age, who finally lost to cancer; and I'd awakened a 25-year-old from sedation after therapeutic hypothermia, still intubated, and talked him through his terror as we tested his ability to breathe WHILE holding his baby-mama and girlfriend at bay. I was not there to be cursed at like a misbehaving printer by some old asshole who deliberately watches Fox News and calls his brilliant doctor an 'Oriental sweetie'.
"Excuse me," I said, holding up a hand for silence. "Do you think I'm fucking stupid? Are you gonna try to pretend you were talking to all the other people in this empty room? No, no, I'm too mad for this right now, I'm gonna go in the hallway until I can calm down, or else I'm going to do something I'll regret. I'll be back in fifteen minutes and you can try again."
I walked out to the ICU nurses' station and plopped down beside a coworker, a little shocked at myself, already dreading the fallout when I walked back into the room. "You look a little peeved," my coworker said, patting my hand. "Patients rough tonight?"
"My guy in forty-two just called me a fat cunt," I lamented.
"Oh honey," she reassured me, "you aren't fat!"
Better a bony cunt than a fat one, I guess. At 58kg, I spend a lot more time worrying about whether I'm secretly a sociopath than whether my ass looks ripe. I made a few awful noises and then had to go in the bathroom until the hysterical giggle-sobbing relented.
When I went back in the room, the pt muttered at me constantly, but he behaved himself just fine until he finally fell asleep. I still use that tactic regularly, and I no longer feel the shaky-legged terror of mouthing off to an asshole when I do. It’s really the only thing that stands between “Elise RN” and “that nurse on TV who strangled that one guy Crowbarrens to death.” So thanks, nasty old coot, I probably owe you my license. Thanks for being sick that one time, so I could lash out at you verbally and learn to defend myself with words instead of snapping and committing a felony.
On this particular shift, though, the one I keep getting sidetracked from, there was no yeast stroke, no cursing racist. There was just a sweet old lady and her hard-working family and a lot of work they couldn’t do by themselves. The antibiotics and fluid hauled her out of sepsis very quickly, and as I prepared to give report, our saintly social worker arrived at their room with an armful of paperwork, ready to guide them through the process of finding help.
I didn’t work the next shift, but our social worker informed me that the woman had gone to a well-regarded assisted living facility with full-time nursing care as soon as she recovered, and they must be treating her well. She hasn’t returned to the ICU since. She is expected to live for quite a few more years, hopefully, and was assigned physical therapy to help her get back into a wheelchair so she could get around and go outside sometimes.
She has a good family, capable of making difficult decisions, willing to admit when they can’t do it all. She’s lucky. She must be loved.
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Perhaps Elise's unfortunate stroke patient, being filled with those colonies of organisms, became a large and vibrant home to new life after her burial.
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Thanks for this, it's pretty relieving to hear how horrific end-of-life can be and come to terms with it so I'm not hemming and hawing and not providing instructions for when I'm unconscious and/or septic, but have a living will and an appropriate DNR orders and what-have-you.
Thanks for all you do, and for letting people know the unblemished truth of horrific medical issues. It's weird being a big walking bag of meat & bacteria, and any information you can get on how shit goes in the worst of times makes it easier to handle mentally if it ever comes to that.
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