So, uh, I’ve been on hiatus.
I’ve been working on a few chapters for a book proposal, and trying to get things pretty enough to be useful for publication, but I really REALLY prefer blogging to book writing (at least in this format) and I’d like to get back to this. So I plan to keep working on the blog, not necessarily shift-by-shift but following specific batches of pts, and work on the book between posts.
The upside to this is: I have a lot to tell you guys about. I expect to update once a week from here on out, and I actually have a backlog of posts ready to go, so there shouldn’t be any major hiccups for a while.
You have been wonderful and supportive, all of you, and I promise that if any of you is ever unfortunate enough to end up under my care, I will wipe your asses with the warm wet wipes.
(I also told a trio of trusted coworkers about my blog, so they could peek over it and make sure it’s both factual and HIPPA-compliant. All three of them immediately identified Crowbarrens. Life is good.)
Anyway. Let me tell you about Mrs. Leakey.
I got her while I was precepting an orientee, because the new kids always get the worst shit. It’s good for them, shows them the hardest and grossest parts of ICU, and gives them a chance to brace themselves before they end up taking three months of post-cath pts with huge sheath IVs in their groins, looking at somebody’s crotch every fifteen minutes every single shift until they go crazy and beg for a nice sepsis.
You scare them, then you give them easy pts, and they’re so relieved not to be doing all the weird shit that they forget how exhausting and complicated even low-level ICU work can be. And they get a chance to try themselves against the awful things, to see what kicks their gag reflex and what doesn’t faze them, and to figure out whether the joy they feel when they get something right is worth the psychological punishment of everything else.
Normally I am all about this. The experience of struggling through a complicated case with the support and backup of an expert rooting for you—that’s what puts the critical care demons in a nurse’s brain, what drives them to read journal articles during their lunch breaks and keeps them talking about vasopressin at the bar with their friends. The stakes are high, and you want your students to feel that, to remember it when they’re tempted to let things slide, and to feel the exhilaration of payoff when the pt lives. You don’t want to leave your students dangling, but you do want them to feel how unsteady the ground can be.
In this case, my preceptee was not doing well. Wen Li* had been with me for about a month, after impressing the interview panel enough with her brilliance that they hired her despite her complete lack of any hospital experience. She came to us from an outpatient clinic, where she had not been permitted to administer medications. She was smart as fuck, and she was not getting ICU at all.
It’s difficult to articulate what she wasn’t getting, but I’m going to try, because after a month of dedicated teaching I have put in so much thought about how to help her that I need to do something with all this info.
ICU nursing, you understand, has three branches to its practice. The first and most obvious branch is skills—your ability to place a foley catheter, to manage a ventilator, to perform CPR and choose the right butt wipe and prepare a pressurized line for transduction. This is, inevitably, what new preceptees want to focus on, because from the outside it looks like the entirety of ICU practice. It’s what we actually do.
The second branch is less visible, but it arises directly from the first. So you know how to assess a patient for pulmonary edema—do you know what that assessment means? What will make it worse, or better? What caused the edema in the first place, and how? What do you do next? This branch is what I call the concepts, including things like pathophysiology and pharma mathematics and the anticipation of what things are likely to come next.
You guys get enough of my nattering that you know how involved the concepts branch can be. And you hear enough of my stories to understand how exhausting the skills branch can be. You also have a good idea, I’d imagine, how much work it takes to get really good at the third branch: the schmooze.
I guess you could call it empathy, but I think this is perhaps a little misleading, because it goes far beyond treating your pts with dignity and feeling sorry for their misfortune. It concerns your ability to manage angry visitors, to help families strike a truce for long enough to watch their grandmother die, to step in and prevent a coworker’s mistake without undermining their relationship with their pt or making them feel ridiculed. Without it, you can have flawless skills and profound concepts, and the first time your pt calls you a shitty shit-eating shitbitch and threatens to bite your shitty ears off, you will have absolutely no idea what to do.
(Hint: do not give this creative linguist a metal butterknife on his lunch tray, or allow a well-meaning CNA to provide him with one. You will end up being chased around a hospital room, screaming like a teakettle, wielding a trash can as a body shield.)
Wen Li was gaining skills at a reasonable rate. I was giving her all the patho/concepts teaching I could manage, which I feel is no small thing, and although she didn’t seem to be retaining much of it, I was slowly gaining ground by breaking concepts down into small pieces and going back over them from day to day.
She had zero schmooze. Less than none. The week before this, we had a comfort care pt whose sons had finally decided to pull out the tube and let him go; Wen Li had attempted a full, vigorous bed bath while I was out of the room. She had also tried to kick his family out of the room for the duration of the bath, despite the pt being on the verge of death, then grudgingly agreed to let them stay and watch their dying father be stripped and scrubbed.
I think she wanted to make sure he was clean before he died—I had impressed upon her my determination to make sure my pts are clean. She just didn’t realize that, if a pt is actively dying, their time with their family in relative comfort is the most important thing, because you can wash a dead body as much as you want without bothering anybody.
What mattered to her was the how, the method of action, the performance. The why did not come easily. And the human element, the who, seemed to escape her completely. Comfort measures, pain medicines, the little things we do to make sure our pts are comfortable, seemed to slip through the cracks—there is no quantifiable credit, in nursing, for being kind. Only for being right.
Wen Li was proud of her skills. She wanted to be perfect. This made it very difficult for her to admit when she was wrong, to ask questions when she didn’t understand, or to address things she didn’t know but thought she could probably work around.
Every shift with her was increasingly difficult. We still had not put together the basics of heart failure or of diabetes, which you can imagine was a nightmare for me, because I will literally stand on street corners and preach about diabetes for sixteen hours at a time if I’m not stopped.
We were now taking much heavier pt loads, two very sick pts at a time instead of the initial one moderately-sick pt per shift, but I still couldn’t turn her loose to give pts their medications and provide basic care. Unsupervised, not comprehending the basics of pathophysiology, she would very skillfully draw up, verify, and administer a full dose of furosemide—a potent diuretic capable of dropping a pt’s fluid volume by up to a liter within an hour—to a pt with new-onset hypotension who showed signs of fluid volume depletion. Her administration skills were flawless, the central IV was scrubbed to surgical perfection, the furosemide was diluted and pushed slowly to prevent the rare side effect of tinnitus, and the line was double-flushed to prevent clotting. And yet we spent the next two hours replenishing the pt’s fluid volume and discussing what, exactly, should have warned her about hypovolemia.
“I know what to do,” she had said that afternoon, pushing her notebook away. “I’ve seen you do it thirty times now.”
“You can watch me do it a hundred more,” I replied, “and it’s not going to teach you shit except for how to do it. How many times have you seen me not do something? How did I decide each time not to do it?”
“So tell me when you’re not doing something, and I’ll learn that way. I do very well with trial and error.”
It took me a minute to respond to that, so I sat and watched her chart about the care we had just performed, turning a pt and brushing his teeth. We had clashed a bit over the tooth-brushing part; I’d had to insist that she go back and do it right, and only got her to perform it properly by calling it a “basic nursing skill” and watching her closely to make sure she’d done it.
“You realize,” I said at last, “that all of medical history is trial and error, right? It took us hundreds—thousands—of years just to figure out by trial and error that bloodletting isn’t good medicine. We have new techniques come to us every single week, because dedicated teams of researchers are performing hundreds of hours of work in controlled environments, to give us the opportunity to learn good practice without having to kill pts by trial and error. It’s not something you can just feel your way through.”
She didn’t respond. Her lips moved while she read the charting spreadsheet. I wasn’t sure she’d even heard me.
“And you’re not going to see every possible scenario before you’re done with orientation,” I added. “There is just no way you can memorize a list of reasons not to perform each individual bit of care, even with your excellent memory. You have to know why you’re doing it, and how it works, so you can decide for yourself in each moment whether or not it’s appropriate to perform. You have to know your concepts, Wen Li.”
This, even more than the schmooze, had been our problem ever since. She was smart—brilliant even—and it frustrated both of us terribly to see how much she struggled. She was all about method, skills, practice; but these things do not an ICU nurse make.
I started to suggest that she try out a few shifts in the surgical suite. Each skill that she acquired, she performed with razor precision; her sterile technique was spectacular. She followed directions instantly and accurately. She would make a hell of a scrub nurse.
Somewhere along the way, though, she had picked up the idea that ICU work is prestigious, the pinnacle of nursing work. She was determined to “make it.” And yeah, I get it, ICU nurses get premium pay and a little bit of bragging right… but we also see a lot of body fluids, a lot of rotten flesh, a lot of indignity and stress. I’ve cupped my gloved hands for a grown man to shit into. For every shift I wrap up feeling triumphant because my pt is still alive, there are about ten shifts I spend wiping ass and gently waltzing a delirious pt into a recliner for an hour of two or sunlight by the window, while they pee down my leg. It’s exhausting, demeaning, and nauseating.
It’s only glamorous work if you’re a martyr or a liar. It’s only rewarding work if you’re wired for unlikely joy.
And the joy today was especially unlikely. Our lower-acuity pt was a tragedy in a hospital bed; I’ll get back to her in a bit.
Our new, higher-acuity pt, Mrs Leakey, was here for a “post-surgical sternal infection with abscess.” The smell as we hooked her up to her lines and EKG leads and drips promised something incredible beneath the lumpy dressing on her chest. Wen Li already looked unhappy, and the pt’s blood pressure hadn’t even properly tanked yet.
Fluid, three liters, for hypovolemia—the pt was headed into septic shock. She should have been brought in days before. She had undergone open-heart surgery a month and a half earlier, after a dispute with a surgeon who had declared her too high-risk and counseled her to move toward long-term hospice and comfort care, and when he finally broke down and did the procedure, her recovery had been very poor.
When she’d finally stabilized at the other hospital, they’d put in a tracheostomy and a feeding tube—trached and pegged—and sent her off to a poorly-regarded local rehab facility, the cheapest one her son could find. No family members would answer their phones (and, horribly, no family members ever did.) She came to us with a note from the facility’s doctor indicating that she had popped a fever two days before and had started to show redness and weeping from her partially-healed sternal incision yesterday.
As luck would have it, right around the time we got her blood pressure moderately stable, the open-heart surgeon—not the ex-aerospace engineer, but the exceedingly tall one with an apologetic stoop to his shoulders and a deceptively gentle face—dropped by our unit to check on his pt from yesterday. Somebody herded him into our pt’s room, promising “something really interesting,” which is apparently as irresistible to cardiac surgeons as it is to nurses and blog readers. With Dr. Graham at the bedside, we opened her chest dressing, and let me tell you, that infection did not start yesterday.
Just beneath the notch of her collarbone, an open, draining abscess belched yellow pus and stringy gray slough like a Yellowstone mud-pot. The ventilator filled her lungs for the space of a breath, and a huge bubble erupted from the morass and slung putrid filth across her chest.
Then the ventilator let her exhale, and the rotten lips of the wound flapped inward as the negative pressure sucked air into her chest. For a moment, I glimpsed empty black beneath the filth. Wen Li gagged, groaned, and ran out of the room. Dr. Graham recoiled from the bed, coughed into his shoulder, and took a deep breath to recover his voice. “Chest X-ray,” he said, “wound culture, Vaseline gauze dressing, call the secretary to put her on the OR schedule for tomorrow, 0700. Ugh, keep it covered.”
I had already gone for the Vaseline gauze. Any open sucking chest wound gets Vaseline gauze, which makes an air-tight seal. Also it smells strongly of antiseptic, which is better than the putrid-sweet stench that rose from the wound. Dr. Graham left in a hurry, already texting his partner (the ex-aerospace engineer, henceforth described as Dr. Nasa) to consult.
I finished dressing the wound and went out after Wen Li, who still had not come in. She was in the hallway, shivering as she charted. “That happens a lot here,” I said. “Have you been around gross wounds before?”
She didn’t make eye contact. “I’ll just ask them not to give me pts like that,” she said. “I can’t do that.”
I watched her for a minute: grim-faced, tremulous, white around the mouth. I thought about my first gruesome wound, how I had been nauseated and horrified, but fascinated: drawn back for another peek and another until I was poking the edges with my gloved finger and leaning closer than was probably safe. “This is what the ICU is like,” I said, gently. “It’s okay if the ICU isn’t your thing.”
“It is my thing,” she said, eyes still fixed on the screen. “I can do it.”
“You probably can,” I said. “But you might hate it.”
“I like it,” she said sharply, and cut off my response by standing up and heading for the supply room.
Our other pt was easier to care for, and if you knew nothing about her story, she seemed fairly boring. Mid-thirties, pretty, with high-quality tattooed eyeliner and lovely eyes; Jelena breathes for herself, needs no IV drips, and sits in bed looking out the window most of the time. She is nonverbal, follows no commands, and urinates predictably every six hours.
A month ago, she spoke in broken English. She came here from Croatia to escape an abusive, stalking boyfriend, leaving her parents and cousins behind in her search for asylum. She had an alcohol problem, but had ostensibly never taken drugs until she met her current “boyfriend,” who was most likely a human trafficker who preferred his victims addicted.
He had got her drunk, then given her something, or shot her up with something. She’d lost consciousness, vomited, and aspirated. When she was brought in for respiratory arrest, we assumed she was a heroin addict who’d overdosed, but her extreme sensitivity to opioids and her flawless veins convinced us that heroin wasn’t her thing. In addition, she was profoundly hyponatremic—her sodium levels were so low that she seized. We pulled her back around, got her extubated, and discovered that the “boyfriend” who’d dropped by wasn’t exactly the life partner we’d imagined.
Half out of her mind with medication and delirium, Jelena could barely speak English, but with a translator’s assistance she told us that her “boyfriend” had been making her pay off debts by “visiting his friends.” She wasn’t terribly lucid, but she was beginning to recover, and we didn’t expect her to be fully alert just yet. She remained severely hyponatremic, which made her loopy and confused, because we couldn’t correct her sodium entirely just yet. Once someone’s sodium drops to an unsafe level, you can’t just hand them a drive-through burger and let the salt sort them out. A rapid rise in sodium can cause severe brain damage, stripping the myelin sheathing from major nerves in the deepest parts of the brain.
I’m still not sure how it happened. I don’t think anybody knows exactly what went wrong. Despite tight control of Jelena’s sodium intake, she was already up against the wire from the normal saline boluses (which contain salt) that she had received in the ambulance and in the initial hours after her respiratory arrest. Her sodium spiked out of control; pure water boluses failed to correct the surge; and a day after she was extubated, Jelena’s brainstem stripped itself catastrophically and she dropped into an irreversible quasi-vegetative state.
Now she sits in bed and looks out the window. She makes facial expressions from time to time; she cries aloud, or laughs; her hands are beginning to contract and require painful therapy and muscle-relaxing drugs; she does not recognize eye contact, and her gaze slides away as if the world around her is the surface of a frozen lake. Her tattooed eyeliner is perfect.
I am very careful with her. I have no way of knowing whether her mental state is accurately reflected by her physical ability. We don’t even have a language in common. And yet, sometimes her eyes will snag for a moment as they wander around the room…
Her visa expires soon, apparently. Her immigration lawyer came to see her and is at a complete loss. There’s no way to send her back to Croatia; there’s nobody to take her. Her parents are very poor and her violent ex still wants to kill her. No long-term care facility will take her, since she has no insurance and no money and no Medicare. Our facility is legally bound to provide basic care, at our own cost. I guess she’s ours now.
Her needs go pretty far beyond basic care. We’re all learning a lot about physical rehab, which is not something ICU nurses usually do. If she had money, she would be getting rehab from specialist physical therapists instead of our facility’s inpatient PT and our nurses, but she doesn’t have money and there’s no law mandating that she receive that care. So we’re all learning to provide the care she needs, because there’s no other option, not really.
In healthcare like this, bodies are sacred. Humans are precious. The things that happen to our pts are not boogeyman stories of sin and retribution; they are things that could easily have happened to us. We are all, shift after shift, repaying a terrible debt that we hope never to incur, and the dedication with which we pay that debt (knowing that we aren’t required to; knowing that we may be overpaying) is what tells us the kind of nurses we really are.
Navelgazing. A bit self-congratulatory. Jelena is an easy pt to care for, and is often paired with crashing pts whose next twelve hours are likely to be a one-room horror movie come to life. Wen Li, who could not bring herself to be in Mrs. Leakey’s room for even a few minutes at a time, focused her care on Jelena for the rest of the shift, while I worked Leakey like a bellows.
Her modest pneumomediastinum—air in the mid-chest where the heart sits—was stable, and her disgusting chest wound was covered tightly, so most of my work for the rest of the day was centered on her blood pressure and her urine output, which had plummeted to almost nothing. Her kidneys were taking a massive hit from the sepsis.
I also called the rehab facility and asked to speak to one of the nurses, whose name I had found in a bit of transferred charting. As luck would have it, he was working that day, and we had a brief conversation about Mrs. Leakey’s last few days in rehab.
“She got sick about a week ago,” he said. “Her incision was pink and oozing, and the part at the top swelled up and then turned boggy. She’s had a fever for… two weeks? I think? They had us put Bactrim on it and cover it with gauze. Three days ago the abscess ruptured, so we lavaged it with saline, but it didn’t really help. The doctor doesn’t do weekends, so as soon as he came in on Monday we had him look at it, and we immediately transferred her to you.”
“Thanks,” I said, transcribing his tale to a note, and paged the social worker—time to have that facility investigated. Again. Jesus.
Then I heard the distinctive chuckle of one of our infectious disease specialists out in the hallway, and dove out to accost him. “I know you haven’t been consulted on this yet,” I said, “because there really hasn’t been time, but you have GOT to see this.” Ten minutes later, Dr. Leon staggered back into the hallway looking a little green, and set off to find the intensivist for a very thorough consult. It’s not required to get the ID docs involved with every wound, because not every wound is infectious, but given the nature of their specialty I think it’s only polite.
Who doesn’t want to see big gross sucking chest wounds that throw clots of rotten flesh in the air every time a pt takes a breath? I mean, that is some sweet shit. I want to frame a picture of that thing and hang it on my wall.
Of course, having a huge gnarly infection next to her heart and a gaping, slurping hole in her chest wasn’t doing Mrs. Leakey any favors. During my afternoon assessment, I heard crackling sounds in the bases of her lungs, indicating that fluid was building up in her lungs.
Her heart wasn’t pushing blood very well, and it was backing up in her lungs even while her blood pressure plummeted in the rest of her body. It took more PEEP to ventilate her, more oxygen to keep her levels up, and more levophed to tighten up her peripheral blood vessels and route blood to her vital organs instead. By the time the shift ended, Mrs. Leakey was in deep shit, and I knew that the next morning would be her last chance to get surgery before she was too sick to operate on. Knowing this, I exhorted the noc nurse to stabilize her at all costs by 0600, or get ready to code and then bury her.
Then I looked over Jelena with Wen Li and the oncoming nurse. With her arms in the braces we used to keep her wrists retroflexed against contraction, and her eyes wandering dreamily around the room, Jelena looked as if she’d just sat down in the bed for a few minutes before heading home for dinner. Wen Li described the exercises she had worked Jelena through, stretching her hamstrings and working her toes, and we headed to the break room to clock out.
Wen Li and I had a talk in the break room. A debriefing, I think is the official term, but in the terminology of my backwoods youth I think it would be called a come-to-Jesus meetin’. I laid it out for her: she was desperately behind in her training, struggling to provide appropriate care, and obviously miserable in ICU work. She was, in her current state, set up to fail; she could not possibly be ready to assume one-on-one care for pts within the next month unless something changed dramatically. I didn’t lie to her—I couldn’t trust her alone with a pt, and I told her so. I explained that she was very smart and obviously learned skills quickly, and that I thought the problem was the setting, that ICU work was not ideal for her and that she would probably be happier doing something else.
I could tell, I said, that she was compassionate and determined. I could tell that she was capable of being an excellent nurse. I could tell that she was miserable here, and that she was wasting her abilities on a specialization that didn’t suit her at all.
She endured my speech without making eye contact. I can only imagine what was going through her mind; I would, in her place, have been humiliated, angry, frustrated, desperate. I reminded her of the good work she’d done and of the skills she’d demonstrated, of her frankly stunning ability to memorize, of her dedication in providing care for Jelena that went above and beyond her duty.
Wen Li just stared at the wall, her jaw working, and for a moment all I could see was Jelena’s absent gaze. Then she said: “I’m going to do well in the ICU,” and left.
On my way out, I passed Jelena’s room again. The noc nurse pulled me aside and asked, concerned, how long it had been since her last round of stretching exercises. “Her legs are really locked up tight,” he said. “I had to give her a muscle relaxer before I could get them straightened out. Did she get PT today?”
“Wen Li did it,” I said, and went home with a heavy feeling in my chest.
The next morning, Mrs. Leakey went to surgery; Dr. Graham removed her entire rotten sternum and an eight-inch almond-shaped segment of chest with it, placed a wound vac in the resulting hole, and planned an abdominal skin graft for when she stabilized. By the next evening, she was beginning to recover from her sepsis, although the damage to her kidneys was severe.
Wen Li and I worked together for one more shift. She held a much-needed antibiotic and administered a contraindicated dose of metoprolol, failed to recognize a pt’s impending renal failure as their urine output dropped to almost nothing for four hours, and used a caustic cleaning wipe on a pt’s face to wipe up saliva. I caught her copying a previous assessment in the charting, failing to note several major changes that should have been obvious; I caught her charting things she hadn’t done, turns she hadn’t performed, care she hadn’t given. I caught her reading my email, checking my sent box to see what I’d told the clinical educator about her.
I spoke to the manager, who pulled her aside for a chat, and she told him that I focused too much on pathophysiology and wouldn’t leave her alone with our pts to learn by trial and error, and that I was a bad teacher and had insulted her repeatedly by telling her she shouldn’t work on the ICU.
She was sent home on administrative leave, and gently informed that she should turn her resignation in during the leave so that she wouldn’t be marked as “fired.” She declined.
I felt horrible. I felt like I had failed her. I felt like I had somehow thrown her under the bus, taken her to task when I should have communicated better. I felt like a piece of shit.
Until my manager told me that she didn’t like my patho. I figure if she couldn’t appreciate my pathophysiology teaching, she would have hated the ICU forever. I mean, yeah, my personality can be appalling and my organization skills can be haphazard and my practice is at times weird and obsessive… but son, I am proud of my patho.
I still wish she’d taken my advice. She would have done well in the surgical suite. I don’t think the dishonesty took root until she realized she couldn’t handle the reality of ICU work, and I think if she’d gone for the OR instead she would have been happy and competent and ferocious. And you don’t need a whole lot of patho, or of schmooze, to keep a perfect sterile field.
ICU isn’t for everyone. And you know what? That’s okay. I wouldn’t last one god damned day as a scrub nurse.