I apologize for the brevity of this post. For those of you that follow my scrawlings on Something Awful, I’ve been doing an AMA for the last twenty-four hours on the BYOB forum, which has diverted just a little of my writing powers.
I did manage to rant with embarrassing fervor about fruit that I like.
Sometimes the ICU runs like you expect it to: occasional periods of panic, lots of gross chores, and a slump around 1600 when you can catch up on your charting. Sometimes it gets a little crazy, and if you have a really rowdy pt with a lot of things going wrong, you can easily spend a whole shift on your feet and do all your charting after you’ve passed your pt to the next shift. And sometimes, the whole ICU loses its goddamn mind at once, and all your pts are desperately high-acuity and breaks only happen if everyone works together, and staffing calls random people on their days off and begs them to come in—not to take pts, but to serve as an extra flex nurse, just to help people get all their chores done.
When this happens, you have to be a special kind of dumbass to actually answer your phone, let alone come in extra. Unfortunately for me, I am that exact kind of dumbass. That week, I worked a lot.
We had quite a census. The hospital was so full that, as I got off the elevator, I heard one of the pulmonologists suggesting to a group of suits that we might have to consider transferring pts to other facilities. And the ICU, which usually harbors a fair selection of telemetry and medical overflow pts who are waiting for rooms, was wall-to-wall critical care, all very sick pts in need of heavy care.
It was so bad that we had to delay scheduled open-heart surgeries. These are the bread and butter of the unit—they have predictable outcomes, high pt satisfaction, and a massive volume of potential victims. Insurance and Medicare both pay for them reliably. In short, pushing back your hearts is a sign that your ICU is slammed to the breaking point.
Another sign that you are up a creek: you’re calling me to ask me for extra shifts. That means you’re willing to ignore my personality and tolerate my verbal pun diarrhea, as long as I’ll help you transport your pts to the CT scanner.
Anyway, the whole shift was a clusterfuck. Crowbarrens had been admitted that morning and was looking pretty harsh; the pt next door to him was a lady from the Deep South who had failed to pick up her antibiotics for a nasty UTI and ended up in sepsis; the lady beyond her had suffered a tremendous stroke and had a dozen family members who were all wealthy, white, and panicking; the guy after that was a known asshole who had refused open-heart surgery and then gone into cardiogenic shock, and was now fighting for his life on a ventilator and a zillion drips.
The lady after that, well… her nurse warned me not to go in there. “But she’s a high fall risk and I have a bed alarm on her, so probably you’re gonna have to go in there at some point, because I have the cardiogenic shock guy and I can’t always get to her as fast as I should. Sorry.”
I went in and introduced myself. She was a shriveled little woman with a shock of dyed black hair on top of a squished face that looked to be short a couple dozen teeth. As soon as I came in the room she started crying hysterically, big guffawing sobs, claiming that nobody had given her pain medicine for hours.
I checked her medicine administration record (MAR) and noted that she had been given 25mg of oxycodone within the last thirty minutes. “It looks like your main medication might not have kicked in yet,” I said, placating, and then turned around. She was asleep and snoring.
Huh. Looks like the oxy kicked in after all. Also, 25mg of oxycodone is a fucking lot of oxy. I usually give doses of 5mg, or maybe 10mg on the outside, to pts who’ve just had open heart surgery. A dose that high is typically indicative of somebody with a chronic pain condition and major tolerance for opioids. It usually means that the person is opioid-dependent in a major way.
Even for people with chronic pain, 25mg four times a day—her preferred dose—was quite a bit. Like, for me, that’s a euthanasia dose. And it was apparently working hard for her, because she couldn’t seem to come around for more than thirty seconds at a time.
Now, I wanna make a disclaimer here. I take care of a lot of people with pain medication dependencies and painkiller issues. It’s not really something that bothers me—it comes with its own punishments, from constipation and pneumonia to social isolation and emotional wreckage. It’s not my job to punish people for their addictions, nor to cure them in a short-term acute critical care setting, so generally speaking I sling opioids with a free hand according to the doctor’s orders, as long as the pt isn’t sedated or forgetting to breathe.
The disclaimer is necessary because, in general, the pts I work with that have pain medication issues aren’t here to get high. They have pain, sure. The pain usually overlaps the medication. They want their pain medication on time, because they fear withdrawal with understandable dread. They maybe want a little extra pain medication to tide them over, because what they normally take just gets them right over the edge of normal, and their bodies are pumping out extra pain right now with their heart attack/sepsis/perforated bowel wrecking their shit.
This woman was something else. She didn’t want her normal medication plus a little extra. She wanted the kind of pain medication that’s usually associated with a hardcore heroin problem. She wanted dilaudid IV, every hour on the hour, and would try to talk us into slamming it hard every time we gave it. She tried to trick everyone who came into the room into giving her extra medication. She threatened to call the medical director, the CEO, and the nursing supervisor every time anyone told her that the next dose of pain medication wasn’t due. And while she was probably experiencing some pain, she was also sedated to the point where she couldn’t wake up, and her breathing was so shallow that she had trouble maintaining oxygenation.
She had thrown herself face-first into her addiction, no holds barred, ready to die on that altar for a little extra high. She wasn’t interested in maintaining, in avoiding withdrawal, in feeling okay. She wanted the first-time rush, and it really drove her crazy that no amount of dilaudid slammed into her veins would ever feel as good as she wanted it to. And she wasn’t able to accept that.
Also, she had a serious personality disorder. I mean, holy shit. She staff-split like nothing else.
Staff splitting is what happens when a pt tries to pit some of the staff against the other staff. “She’s so mean, she treats me soooo badly, not like you! You’re an angel and you’re so compassionate, so much better than all the OTHER nurses who are soooooo mean to me!” It’s a valid tactic, and it actually works sometimes, if your staff isn’t savvy to the phenomenon.
Our staff is pretty savvy. This woman wasn’t having a good time. Everyone she tried to praise at the expense of other coworkers got a little prickly and stood up for their buddies. Her nurses scanned their medication conscientiously, and got it to her a consistent fifteen minutes early—the earliest we’re allowed. There wasn’t any room for her to complain with any real reason, which meant she wasn’t getting double doses of dilaudid.
Most difficult of all for me personally: she had religion the way some people have lice. Christianity and I have a very complicated, if mostly benign, relationship, and despite the painful history between us, I rarely have a Christian pt I’m not willing to bow my head next to while they pray. I figure if the hospital’s chaplain can offer prayers on behalf of pts of all faiths, the least I can do is nod and smile and support the spiritual needs of my pts. Their faith was once mine too.
And there were good things in that broken home. There was comfort, when I shivered in cold anguish in the pine needles because I was afraid to go back to the house. There was a friend, an ever-listening ear, a version of my father that wasn’t possessed by demons or by psychological disease, from whom I could—and needed to—keep no secrets. There was a mythos, a mystery, an endless dreaming well of sweet dark things.
Because of this, the one brand of religious fervor that really gets under my skin is the kind of Bible-thumping that thinly veils something nastier: a manipulative streak, a bigoted agenda, a social compulsion to do what you think everyone else is doing. In this case, she waved her Bible at everyone who entered the room, shouted that God would protect her from suffocation if we gave her more dilaudid, and scolded us in the name of Christ for delaying her ice chips and her warm blankets.
When her nurse was unavailable for a little while because the cardiogenic shock guy tried to crump, and I got to tend her frequent call bells instead, she gave me a five-minute tongue-lashing and insisted that HER nurse take care of her, not some jumped-up extra nurse who probably isn’t even a Christian.
I broke a personal rule and told her that her nurse would be slow to respond for a while, because her other pt was very sick and needed immediate rescue. I added that her nurse had asked me to watch out for her while the other pt was too sick to leave, and that I was at her disposal and would make sure she got her pain medication on time. She responded: “I pay my bills just like that other guy. I’m a patient too! What about my needs? I want her to bring me some ice! I’m just as good a person as he is. God has spoken to me and he says that my needs are important too!”
She was here because she was having a GI bleed. A few years back she’d undergone a gastric bypass surgery, and had managed to stretch her stomach right back out again, drinking something like fifteen Coke cans per day. Somehow she had started bleeding internally, and somehow spontaneously clotted off the bleed, and two days had passed with no further events since her last maroon stool.
One of the first tasks of my shift as a flex nurse: performing an EGD at her bedside. I charted while her nurse pushed medications to keep her sedated. I held her hand while they did the EGD, because her respiratory drive bottomed out before her consciousness did, and she was partially awake for the scope. Not a fun experience, but there’s only so much you can do with drugs.
The EGD showed clean: healthy pink stomach lining, no source of bleeding. Her colonoscopy the day before had also shown us nothing. The bleeding must be somewhere in her small intestine, where we can’t go with a scope. Fortunately for her, whatever had gone wrong in her belly seemed to have repaired itself; she hadn’t lost too much blood, despite the maroon splash zone in the bathroom, and for the last twenty-four hours her blood levels had been totally stable.
She simply wasn’t an ICU pt anymore. She was ready to downgrade to telemetry, maybe medical, and possibly even go home. She would need to see her own general practitioner regularly for a while, but with her bleeding stopped, her total blood loss minimal, and all the reasonable tests we could run coming back negative, there was no reason to keep her here. She threw a fit as soon as she woke up from the EGD, demanding a diet that included “toast and some macaroni,” and while solid food is strictly forbidden to active GI bleeders, we couldn’t think of any reason she shouldn’t have a nice big meal.
As you might have guessed, she didn’t want to leave. In the hospital, she could get IV dilaudid; she could get oxycodone without having to use up her home prescriptions; she had three meals a day plus snacks, cups of ice on demand, and a full audience for her internal distresses. She started hoarding her shit in her room, demanding that we keep it until the doctor could “look at it” (no intensivist looks at poop if they can help it) to prove that it was bloody.
It wasn’t bloody. It was brown, liquid, and smelled heinous. She dropped into a lathery panic every time we tried to throw it out, and her assigned nurse humored her, because you gotta choose your battles sometimes.
Her room reeked like the giraffe house at the zoo. Multiple pans and buckets of ass detritus stewed in the corners as if to fend off demons. I finally barreled in with a face mask on and pulled out my best nurse logic at her: blood turns brown when it sits in one place, so if she left all the poop in her room, the blood in it would turn brown and the doctors would decide she wasn’t bleeding as soon as they saw it. Then, as she hemmed and hawed and chewed on my reasoning, I emptied every receptacle in the room, threw away the bedpans, poured sani-wipe juice into the commode bucket, wiped down the walls, and bailed before she could start quoting Bible verses again.
Mid-afternoon, her doctor showed up and attempted to discharge her. Or downgrade her, maybe, who knows, because after about fifteen minutes of caterwauling, calling upon Jesus and the angels, speaking truth in trust about the blessings of the Lord, and outright crying and kicking the bed-rails, the doctor came right back out and informed the charge that we’d be keeping her ICU status for another day.
And, okay, there’s a bright side to that. If she’d just been downgraded to telemetry status, we’d have had to group her with two other pts instead of just one, and some poor RN would have the worst shift in the history of shifts. Keeping her ICU status meant that she could at least be kept at 1:2 ratio.
Not that her nurse could really spare a full half of her time. The cardiogenic shock guy circled the drain with the kind of wild, pulse-dropping abandon that usually precedes a code, and she stayed at his bedside to manage his drips while I—the extra nurse—dedicated almost all of my time to caring for our GI bleeder and her endless dilaudid hunger.
As the evening progressed and she failed to produce any more gouts of blood from her anus, she started to realize the gravity of her situation. At this rate, with her vital signs stable, absolutely no sign of bleeding, labs positively glowing, and her procedures all showing nothing but shiny pink innard-skin, she was either going to get sent home tomorrow, or the doctor would cut her dilaudid dosage.
So she started hauling herself out of bed to get on the commode every twenty minutes. She would strain and strain, produce nothing, and climb back in bed with a sore tailbone from the hard seat. I put limits on her commode time, because honestly you can get awful skin breakdown from spending too long on the crapper, and countered her protests by pointing out that she was sitting on three absorptive pads and if she had to go in a hurry she could just go right there in the bed.
And I promised her that every half-hour I would come in and help her get up to the commode, so she could try again.
Twenty-eight minutes later, she hit her call bell, and while I was headed to her room she pulled herself over the side rail and nearly wiped out facedown on the linoleum.
I dove into the room and managed to catch her. She screamed at me for taking too long, and I bit my lip and resisted the urge to remind her that literally twenty seconds had passed since she pressed the button. Instead, I helped her to the commode, watched her strain away, woke her back up several times as she drifted off in a haze, wiped and powdered her butt despite the lack of productive effort, transferred her back to bed and caught her several times during the one-meter trudge as she fell asleep on her feet, and put the call bell back within reach.
“I’ve been waiting for my oxycodone for almost an extra half an hour,” she quavered, screwing up her face as if trying to wring tears out of a dishcloth. “I’m in so much pain, I need medication now, I can’t wait forever when I call. I have to get to the commode sometimes!” Her eyes closed halfway, and she continued: “I’m just in so much pain. My oxycodone is forty minutes late.” She let out a snore as she finished the sentence, and her head sagged forward.
I checked her MAR, and while it loaded I gave her the most diplomatic spiel I could come up with. “I promise to stay within thirty seconds’ reach of your door,” I said, “but please promise me that you’ll stay in bed until I’m here to help you. The floors are slippery, and you almost fell just now.”
“Nothing bad will happen to me! I’m a Christian, and God will protect me. Jesus is here with me, I’m not going to trip and fall, I just can’t wait in bed for you to ignore me while I have to go to the bathroom! Every time I press this button, I have to wait thirty minutes before anyone comes in here.”
I could feel my blood pressure rising. I don’t think thirty seconds had gone by all shift between her calls. Every one was dutifully answered by either me, her assigned RN, or the unit secretary at the intercom. “It looks like your last dose of oxycodone was about an hour ago,” I said. “You have about three hours left until your next dose, but I can bring you dilaudid in about twenty minutes, does that work for you?”
Again she struggled to bring up some tears. “Are you trying to make me feel guilty for being in pain?”
“Absolutely not,” I said, but she had already come up with her angle and she was running with it.
“Every time I eat anything, any time I ask for anything no matter how small, everyone wants to make me feel guilty! Everyone guilt trips me! The Lord is with me, and he says I don’t have to feel guilty, he has spoken his word over me and made me pure! I’m having so much pain. The Lord doesn’t want me to be in pain like this!”
Now, when I type it like that, it sounds like a torrent of speech all at once. And, I guess, for her it was. What I can’t convey is the sheer number of times she fell asleep during that speech, or the fact that she ran out of breath multiple times because she simply forgot to breathe in. She probably was having pain, but there was nothing I could do about it without killing her, and I regretfully told her so.
At this point she started throwing things: a blanket, a pillow, a wad of tissue paper she’d crumpled up in bed. “I need dilaudid,” she shouted. Then her eyes rolled back and her mouth drooped open for a good four seconds before she managed to rouse herself again.
I mean, what do you do in a scenario like that? There’s nothing to be done. If you leave the room, she’ll be back on the call bell in ten seconds, and if you aren’t standing in her doorway already she’ll throw herself out of bed and fall. If you stay in the room, every time she wakes up she’ll work herself into a tizzy because she’s not getting opioids Right Now.
I settled for trying to back out of the room surreptitiously during one of her snoring sessions. Unfortunately, she woke up before I could make my escape, and threw another wad of tissue at me. “You’re just like everyone else in this horrible place,” she screamed, “trying to make me feel guilty all the time, leaving me here alone to die! You just want to ignore me and oppress me, because I’m a Christian! You know what I think?” She leveled a look of pure malice at me, grinding her jaw as if the syllables hurt her. “I think you’re—a—Muslim.”
I wish to God, or perhaps Allah, that I had a picture of my face. I know for sure my mouth dropped open. Not because I was angry, or because I felt insulted (maybe a third of this hospital’s staff is of Islamic faith and nobody gives a lukewarm shit who you pray to around here), but because this was the holy grail of patient insults. Usually it’s all “bitch” this and “asshole” that. I’ve had somebody accuse me of “getting off on withholding pain medication,” which isn’t any sexual fetish I’ve heard of but then again I avoid most of the internet these days, and I’ve had a lady proclaim me a ‘trash man baby momma’ and direct me to ‘eat a garbage man ass’.
But man, I’ve never been accused of the high crime of worshiping Allah before. It was fascinating, even delightful. I felt as if I’d seen a rare animal in the wild, or somehow staggered through an eerie twilit forest and stumbled into an unseelie faery ring and found myself in the middle of a Trump rally. This lady genuinely believed that I would be destroyed by her accusation, and the look on her face as she waited triumphantly for me to burst into tears, that shit fed my spirit in a way that few things can manage.
I used to read terrible fanfiction back in the day. I read awful romance novels for a while, but the library was far away and only had a few of them anyway. I have an awful, slavering hunger for really fucking terrible things, for the nauseating joy of staring as hard as I can into the abyss and waiting for it to flinch, for the moment you realize that Dumbledore and Voldemort are for seriously real gonna make out in this story and the author intends to describe the consistency of their saliva. I love horrible things. I think this is part of why I went into nursing.
So yeah, being called a Muslim by a person who thought that was an unforgivable sin… I don’t know much Arabic, but I managed to mush-mouth a half-decent “Inshallah, whaddayawant,” and leave the room before I collapsed in hysterical laughter.
As I departed, she screamed after me: "I am a good Christian and the Lord is with me and I deserve respect! And dilaudid!"
She hated me so much after that, she spent a good half-hour screaming imprecations out into the hallway. Somehow she got the idea my name was “Whitney,” so that added a whole new layer of monstrous hilarity to her diatribes. She started calling the hospital operator and demanding to speak to the charge (which she did every few hours anyway), to the medical director (who wasn’t available, this being 1700 on a weekday and her being an inpatient), to the CEO (who mysteriously could not be connected directly to her room line). The hospital operator eventually called our unit to ask what she should do about the incessant calls, and we told her to ignore them.
At least her hatred of me was useful. The next time the pt jumped out of bed, I cut a deal with her: if she would stay in bed and wait for somebody else to help her, I would stay out of her room completely. If she was patient and could wait for help from someone else, she would never see my face again. She tried it one more time, got to spend ten whole minutes in my delightful company, cried herself purple because my “Muslim” oppression was just so cruel and evil, and stayed in bed for the rest of the shift.
I handed her care off to another nurse, a twenty-five-year veteran of the unit who I’ll call Sharon*, and rewarded myself with a luxurious pee break and a cup of coffee. I figured, if Sharon couldn’t handle it, it couldn’t be handled. And yet, as I emerged from the break room, I heard raised voices from the dreaded room where Jesus was carefully watching our pt’s bowel movements: Sharon had attempted to remove some of the pt’s hoard of Coke cans to place in the refrigerator, and the pt was having a complete meltdown in response. Her screeching grew more and more abusive and spiteful, and finally I heard Sharon’s voice rise in response.
“Get a grip,” shouted Sharon, and stomped out of the room, slamming the door behind her.
I have never seen anything quite like it. If you can irritate Sharon into screaming at you, there is probably an entire host of devils having a pitchfork orgy inside your body all the time. I’ve watched her nod and murmur soothing syllables to raging corporate executives who respond to her lifesaving care as if it’s a personal insult. I never thought I would see her lose her cool.
She stayed in bed, though. Whitney the Muslim was, apparently, deterrent enough.
That night, after the day shift finally escaped, she demanded to see the night charge. Andrew* is a six-foot-four Hispanic nurse built like a linebacker, with a charming grin and a slick way with words. He smiled into the room at her, and she flipped her shit and screamed imprecations at him until he left. Turns out, according to the insight of our favorite pt, Andrew is a Muslim too! Because he’s brown. Because brown people are all Muslims. God, what this lady’s internal life must be like.
The next day she made us all miserable until our saintly social worker sailed into the room, murmured sweet nothings as only she can, and by some weird combination of persuasion and hypnotism, convinced the pt that she really wanted to go home. It took her nurse the rest of the shift to get her packed up and discharged, but god, the quiet that settled in after she left, the sheer relief of knowing that she was gone…
By the time she left, she had reassigned the religious identities of at least four and as many as nineteen people. I mean shit, you could show up for your shift Baptist and go home a Hare Krishna. I did notice that she was completely silent while the one phlebotomist was drawing her blood, the Muslimah with the super nice silk headscarves. Like, completely silent. Maybe she was scared too much to talk. Maybe we should have parked a sitter in there in full burqa just to get an hour's rest from her screaming. The only big drawback is that I would hate to think of her being rude to someone about their actual religion. Nobody should have to sit through that.
Meanwhile, all through these shifts, Crowbarrens deteriorated. Whatever growth was pressing its way into his belly had begun to weep, and they put down an NG tube and sucked almost four liters of bile from his stomach. The intensivist put drains in his pleural spaces and in his abdomen. Toward the end of the evening, with significant looks at each other and with a chill sense of dread, his nurse and doctor started him on a dopamine drip, a pressor to keep his body alive, because he is passing into the degree of illness that requires truly critical care.
The pulmonologist sat down with his wife and explained that Crowbarrens will not be going home again before he dies, unless it’s on hospice. She sobbed and asked him if they could set up hospice. Unfortunately, our palliative care group and all the hospice facilities in the area have fired him as a pt because of his severe behavioral issues, so our social worker is trying to butter one of them up enough to get them involved in his case.
He has made himself DNR.
The last shift I worked, he managed to pull himself together long enough to call his wife a “stupid bitch” and spit at her. Good old Crowbarrens, himself to the last.
I’m not sure if he’ll survive until I return.
Jelena is still living upstairs on the medical floor, still getting nurse-mediated physical therapy, still no rescue in sight.
The cardiogenic shock guy is still, somehow, clinging to life, days later.
Tomorrow, I will be thirty years old.
Anyway, I should post a recap of that AMA thing here, just in case any of you aren’t goons and would like to read it. I think I’ll do that tomorrow.
Great entry as always. I encourage everyone at school to read it (we're still working our way up to starting with new patients next year). Elise's writing style and verbal freshness is a delight.ReplyDelete
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Oh wow, we're very nearly the same age. I assumed you were a bit older than me, because you're an adult doing an adult job and all.. being an adult. I keep forgetting I'm a full-fledged adult with a job who is usually pretty responsible.ReplyDelete
I'm an addict, former addict, whatever you want to call a person who used to use opiates to escape life and has been clean for years but is well aware they're still an addict, and opiods were my poison (I for real want some Dilaudid now). There's a possibility that woman was bitchfitting about pain meds because she was too zonked to realize she.. didn't need to be. I've been there before. I'm' sure you've seen the way high doses of opiods can whittle people's personalities down to the core, and if you're still an addict before anything else, at your core... you're going to be legitimately worried about not getting enough, not getting what you want. Even if you've gotten what you would want if you weren't so stoned you keep forgetting to breathe.
If she had just been relentless about the pain meds, I'd say she might feel embarrassed about what she can remember of her hospital stay, once she's relatively sober. Given the rest of her antics, though, I doubt she's ever been embarrassed by anything. Being an addict does burn out your shame module pretty fast.
By the way, I'm not trying to EXCUSE her behavior at all. I'm guessing you deal with patients obsessed with their pain meds for reasons besides pain control pretty often, and I thought this might be insightful. Not many people (even healthcare workers, in my experience, although I haven't interacted with many who deal with ICU patients) know both A. that being stoned on opiods changes people's behavior, and B. can cause weird obsessions with their core fears, because they're not alert enough to properly evaluate their fear. Obviously, this woman wouldn't have benefited from caretakers knowing this, but I imagine other patients might.
*"Even if you've gotten what you want and would know it if you weren't so stoned you keep forgetting to breathe."Delete
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Having been an ICU RN over thirty years ago, I found myself laughing as hard as I was crying.ReplyDelete
Things [nursing care] haven't changed much. neither have patients. We were taught to make "independent" care decisions when, in fact, when we worked well, we worked collaboratively. You and your team are valiant!
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