Saturday, January 9, 2016

Wishbone, Leah, and the Return of Crowbarrens

Every shift, we introduce ourselves to our pts, explain how long we’ll be there today, and talk about our goals for the day. Some people have very simple goals: don’t die is popular, as are things like control pain and get out of bed. Some people will have procedures during the day, endoscopies or central line placements or dialysis.

Occasionally, the most important goals aren’t things we can cheerfully schedule with our pts: come to peace with impending death, or manage not to shit directly on anyone’s scrubs. In those cases, we find simpler goals: order breakfast and lunch early so they don’t have to wait, take a walk and get some sunlight, that kind of thing.

Then we do our assessments, because nothing helps your day get moving like peering at some guy’s butt and hoping that pink spot on his tailbone isn’t turning into a pressure ulcer.




Then, if we’re well-behaved and our minds haven’t already wandered off in search of 0800 meds and asphalt coffee, we’re supposed to write our names and our goals on the whiteboard. Each room has a whiteboard on the wall, conveniently located behind the computer monitor so that nobody can see it, too far from the bed for anything written there to be legible, with exactly one dried-up marker balanced on top. These can be valuable tools if you have a room full of panicky visitors who need something to fixate on, or if you need to keep a lot of information handy for transcribing later, or if you want to keep all the family’s phone numbers in one place.

I am notoriously terrible about updating the whiteboard. So is everybody else, because nobody remembers to replace the last nurse’s name when their morning is already thirty minutes behind. Which is why half the boards on the unit read “Shelley RN”—she’s a fucking overachiever who does everything right, and we are useless schlubs who will let seven shifts in a row go by without erasing her name. (I can’t be mad. Shelley may be the Joint Commission’s charting wet dream, but she’s also one hundred percent on every shift she works, and this makes her one of our best high-acuity nurses.)

So when I’m preparing to receive a pt, and I have enough time to fine-tune the room, I slap a few quick scribbles on the board before they arrive: Elise RN, control pain, oxygenate, stabilize. Then I don’t have to worry about it for a while—in fact, if I’m lucky and noc shift is as lazy as me, my name might still be on the board next morning when I come back to work.

This particular morning, I had spent the first four hours discharging telemetry pts at top speed, trying to clear my slate to receive a GI surgery pt by the name of Wieszczek* who had gone under the knife at around 0700 and was having one hell of a ride on the table downstairs. If I could get my pts out the door before he arrived from the OR, the charge nurse promised me I could land him one to one.

If not, my tele pts’ discharges would have to wait either until I could get around to them or until the flex nurse could wrap up my work for me. It wouldn’t be the end of the world, but it’s sloppy, and it’s hard for me to focus when I know I have other pts just sitting around waiting on me. And it’s kind of rude to them, because they want to get home to some decent food and a bed that doesn’t feel like a rubber bar mat, and the extra hour or two of hospital time just drags.

Fortunately, I have become very good at quick discharges. Mostly this just means I’ve learned to use our charting program at top speed, and am pretty good at explaining things to people in ways that they understand. Discharging requires a doctor’s order—not always a simple hurdle, since sometimes doctors wander off in the middle of the shift to take care of their other pressing responsibilities—and then a list of tasks for me to complete before they can leave.

Medications for discharge, and any home health care equipment, have to be finalized and called in to the pharmacy or medical supply agency. Drains and IVs need to be removed; clothing and belongings packed and double-checked (everyone seems to leave their cellphone chargers). I print out take-home instructions and a hospital summary, list all the medications they’ve taken and when, and the next time they’ll need to take them. I write notes about their care plans and education, and tick about six dozen little boxes to indicate that we actually took care of the pt while they were staying here.

Then I go in the room with a couple of pens and a ream of paperwork, pull up a chair, and start educating.

Every new medication and every dosage change requires some explanation. (I usually start the education process well in advance of discharge when I get the chance; if a pt is awake enough to understand that they’re taking a pill, or their family member is in the room while I’m giving the pill, somebody is getting educated about what I’m administering.) I tell them common side effects and what to do if they miss a dose, a little bit of pharmacology in layman’s terms, and a sheaf of paper to be read at home with a slightly more in-depth explanation.

We talk about what happened to them while they were in the hospital, why they came in, and what they can do to avoid coming back. We talk about smoking and why it’s crucial that they stop. We talk about warning signs that demand a doctor’s appointment, or an urgent care visit, or a call to 911. I make sure they have their last round of pain meds before they leave, and we sign the paperwork together, and then I call a volunteer to wheel them down to the lobby so they can leave.

You can see why this might take a while. And you can probably see why almost nobody gets discharged from the hospital before 1100. Thus, you can probably surmise that I was running around like my ass was on fire for the four hours before this pt arrived.

And I got both of my tele pts out the door.

Which turned out to be a really damn good thing, because Wieszczek’s case was a complete disaster from the moment the elevators opened. Somehow in transit all his lines and wires had become so entangled that by the time the door dinged, the bed couldn’t be moved without tipping over the IV pole and hauling on his arterial line. I managed to squeeze into the mess and help dislodge the offending snag—some metal chunk of the bed had snared itself in a coil of tubing—and we finally got him out into the hallway, still unconscious and intubated, the RT squeezing his breathing bag every few seconds to keep him ventilated.

When we reached his room, we got another surprise: somehow his twenty-something daughter had wandered into his room already instead of staying in the waiting room, and was having a complete breakdown in the corner. Eyes wide, tears streaming, gnawing on her fingers and sobbing aloud—this is not something you want happening in the room while you’re trying to land an unstable pt from the OR. I don’t think she saw much of her father in the bed, considering that the entire OR team was crawling all over him trying to manage lines and tubes, but she had definitely been working herself up to see (and react to) something horrible, and before we’d even realized she was there she started screaming and wailing.

I ushered her into the hallway and flagged down a coworker to guide her back to the waiting room. Then we set to work hooking him up to the ventilator, pumps, monitor, suction, and all the dings and whistles the hospital room had to offer. As we set everything up, I realized that his daughter had written on the whiteboard.

I mean, she had completely erased everything but my name, and markered in her own versions. The board introduced me to ‘Wishbone’, whose care plans included “Get better in a goddamn hurry” and “Eat a bowl of Tommy’s gumbo.” In the space where I usually write family phone numbers, she had written a quick scrawl about her father: “A hard-workin’, trombone-playin’, Cadillac-drivin’, SUPER DAD who never gives up, never stops smiling, never met a stranger, never put up with nothin’!”

She had written it in Sharpie instead of dry-erase marker. I made a mental note to get ‘Wishbone’ looking good before I let her back in the room.

Wishbone was here because his guts had done something terrible. He had a major allergy to dairy—not just an intolerance, but an allergy—and somebody had done that thing to him that people love to do when they hear someone has an allergy. Yeah, they had poisoned him. Some asshole had made some kind of dip at a party, and assured him that they’d made it entirely out of soy and almond milk when in fact it contained sour cream. Turned out, this self-righteous chef didn’t believe he was “really allergic” and wanted to prove him wrong.

For the next three days, Wishbone had suffered agonizing cramps, increasingly bloody diarrhea, and debilitating intestinal swelling. Finally, the morning after he’d checked himself into the hospital, his wrecked innards had become so swollen and damaged that they ruptured.

Just a little note here, for anyone reading this who might be tempted to test someone’s allergy status for themselves: DO NOT DO THIS THING. Nobody gives a quarter of a wet fart whether your coworker’s cousin is really gluten-intolerant or allergic to tomatoes, or just secretly trying to get attention. If you don’t want to cook something that accommodates an allergy, just cook whatever you want and label it appropriately. I promise you, they’ll get the message that you don’t like hearing about their allergies.

I really wonder what amateur allergy detectives think will happen when they make their big reveal: GASP, the salad had peanuts in it after all! Everyone will stand up and clap, and the malingering liar will slink away into the shadows, never to be seen again! I mean, what the fuck, best case scenario everyone will look away awkwardly and the faker will move the goalposts and insist that her allergy doesn’t show immediately but she’ll certainly have diarrhea for the next week. Worst case scenario, you get to watch somebody’s kid die.

Or, in this case, you get the satisfaction of putting a guy through abdominal surgery so surgeons can remove a length of his gut and wash out all the shit that spills from his broken bowels and open an ileostomy to divert everything away from his ravaged colon. You know, if you’re into that.

Wishbone was in for one hell of a ride. He was teetering on the edge of sepsis and needed tons of fluids to replenish what he was losing to the full-body swelling that comes with catastrophic infection. Pressors kept his blood pressure up and his toes cold and blue; the ventilator breathed for him, forcing air into lungs so stiff from swelling and pressors they could barely transfer oxygen into his blood. He was also on high-dose steroids.

No, we weren’t trying to get Wishbone swole. Steroids are actually quite common on the ICU, and their side effects can be simultaneously life-saving and devastating, because anabolic steroids—the muscle bulkers—are a relatively small subset of the huge steroid family of body chemicals. To give you some idea of the scope of this spectrum, both cholesterol and testosterone are steroids. (Thus the -ster- infix.)

The steroids we give in the ICU are typically glucocorticosteroids—that is, glucose-mediating steroids secreted by the adrenal cortex. Gluco-cortex-o-steroids. Naturally, they do a hell of a lot more than mediate glucose, but that’s one of the biggest effects they have on the body: raising your blood sugar in a hurry.

Why the fuck do you have some chunk of meat in your body, secreted by your adrenal glands, dedicated to skyrocketing your blood sugar? Let us explore this question by telling a story.

If you’re out camping and you see a bear and the bear sees you too, you’re going to need some things to happen in your body very quickly if you want to survive. Adrenaline and its buddy nor-adrenaline take care of this immediate response, jacking up your heart rate and blood pressure, signaling your body to make a lot of energy (glucose) ready for rapid use, and diverting blood flow from your gut (you can digest later) to your muscles (you can run now). You might also piss and/or shit yourself, because if you gotta sprint for the horizon, you don’t need the weight of a full bladder and gut. Adrenaline and noradrenaline are here to help you jettison the extras.

These chemicals are so potent and so fast-acting that we use them in the ICU as pressors.

Yes, adrenaline is also known as epinephrine. Your adrenal glands sit on top of your kidneys—thus, epi-nephrine, literally “on kidney.” And nor-adrenaline, the buddy chemical, also goes by norepinephrine, whose brand name in a bag is levophed. Yeah, the nasty pressor that makes your toes drop off. You can see why you don’t want this pouring into your system all the time.

But supposing that, in the process of running from the bear, you get completely turned around and lost and now you’re wandering through an entire forest full of bears. You’re gonna be here for days, eating nothing but granola bars from your pockets and thimbleberries from the riverbanks, sleeping for thirty minutes at a stretch when you can’t stay awake anymore, hiding from bears and jumping at every noise in the brush. You’re going to need quick energy at a moment’s notice; you’re going to need your resources diverted from useless shit like “making sperm” and “building dewy-fresh skin” to really crucial stuff like “grow monster quads” and “staying awake all night.”

You can’t afford to get sick here, in bear country. You can’t afford hay fever or asthma. You can’t spend a lot of effort on keeping your skin supple and healing all its little cuts. If you get a wound, you can just haphazardly scar it shut. If you have an infection, you can worry about mounting an immune response later, once you’ve escaped the bears. If your lungs are in danger of being damaged by cold air or weird pressure changes or irritating chemicals, or if your body just thinks it’s in danger and reacts by clamping your airway shut in a huge asthma attack, well… you can grow lung tissue back, later, if you survive the bears.

And you can’t just keep making deadly pressors to spur your current resources to the max. Eventually your body will give out. You’re gonna need to remodel your innards to respond to lower doses of adrenaline, and to stay primed for disaster. Your body is going into stress mode, and for that it needs a steroid.

These glucocorticosteroids are made in the adrenal glands themselves, right next to where adrenaline squirts out into the body. They aren’t nearly as powerful, but they do some of the same things, like keeping your airways open even when they feel threatened, diverting resources from your skin and stomach to your muscles, and shutting up your immune system when it gets mouthy. They do this indefinitely, changing your whole body in response to stress.

They are not good chemicals. Over time, elevated cortisol levels—that is, the primary stress steroid hormone—can really wreck your shit. Your skin thins and tears, inside and out; your blood vessels scar instead of healing, forming scabs and lumps that grab cholesterol and platelets and turn into huge plaques. Your guts struggle to process the protein and nutrients you need to keep yourself healthy. Fat deposits form in strange places, tossed into the corners of your body for fast access rather than stored in the proper places that look pretty good with some fat on them. Sure, your allergies stay under control, your immune system is too gobsmacked to mount a decent case of sepsis, and your asthma- or COPD-ridden lungs relax open. But the cost to your body is enormous.

And if you have wounds, like huge surgical wounds where half your guts were chopped out… your wounds don’t heal.

So here was Wishbone, packed to the gills with steroids to interrupt his sepsis and knock out his allergies, pinched all over with panic-hormone pressors, trying to get blood flow to his guts and seal the slash in his belly. I knew that first day it was going to take him quite a while.

It took us days to get him extubated; his pain was difficult to control, and he went into a panic spiral every time we dropped his sedation at all. His daughter clung to his bedside, increasingly pale and drawn, watching her father struggle to heal against the barrage of chemicals that kept him alive at tremendous cost. We tapered the steroids slowly, and slowly he gained ground, until we were able to pull out the breathing tube and let him wake up completely.

Typically, on the ICU, things either go quickly or they go badly. It’s not uncommon for the healing process to drag out over days and weeks, even months; but the longer you’re on the ICU, the more likely your body is to run out of reserves and pull something really bad on you. A clot, an infection, a fall, a complication of inactivity—with every day you spend in the hospital, your risk rises. And if you were super sick to begin with, you’re already starting from a place of high risk.

So every time Wishbone made a little progress without a major complication, it was a huge deal for all of us. He swung his legs over the side of the bed and, with our help, dangled his feet on the floor; he had his central line removed and a PICC line placed; he tolerated a few ice chips, had a CT come back clean for intestinal leaks, spent twenty-four hours in a row without any pressor support. His kidneys didn’t fail. His lungs resisted infection. His blood flowed without clotting.

Wishbone, against all odds, was escaping the bears.

Finally, after weeks of IV nutrition and bowel rest, the GI doctor put his stamp of approval on a solid diet for Wishbone. Nothing challenging, mind you—an egg salad sandwich on white bread, untoasted. We put in the order and I sat by his bed, running over the beginnings of discharge education, knowing that he and his daughter would be going home in a few days. We talked about his medications, and about his car; we talked about physical therapy, and his jazz band and his trombone. His daughter works at a sushi place, and he couldn’t wait to head back there for happy hour. I made his appointments for the next few months, and taught him to use his ostomy appliance.

The egg salad sandwich arrived, and I set up his tray: fork, juice, napkin, covered plate. As we talked, I did the automatic nurse thing and opened his sandwich for him, to slather mayonnaise inside, because an egg salad sandwich without mayo is like Yellowstone-flavored kindergarten paste.

From the egg salad sandwich rose the unmistakable smell of ranch dressing.

It took me a moment to realize what I was smelling and seeing. There was definitely, absolutely ranch dressing poured on the egg salad. I would never have expected it—ranch on egg salad sounds like some kind of obscene joke. But, you know, it’s a fucking hospital cafeteria, they make grosser dishes. (Do NOT eat the “autumn lentil stew.”)

And you know, for all my ranting earlier, something in my midsection wanted to say: I’m sure it’ll be fine, his chart says ‘dairy allergy’, I’m sure nobody in Dietary would put ranch dressing on an egg salad sandwich. Ranch dressing has buttermilk in it, isn’t that low in lactose? Nonsensical, bargaining, rationalizing thoughts.

I mean, here I was looking at a guy I’d spent almost a month trying to save, a guy who was only here because some person fed him dairy, and I didn’t want to believe anything would go wrong if I gave him ranch dressing. I had thirty other things to do. He was hungry, and it would be cruel to make him wait longer for solid food. It was just, you know, a little ranch dressing.

For a few moments, I saw some dark apathetic thing lurking inside me, something that didn’t want to believe in a food allergy because it was inconvenient, something that figured I could just give him antihistamines if it was such a big deal. It wasn’t a drug, something that I needed to scan because it could be dangerous. It was just a sandwich.

Then I took the sandwich away and told him what was wrong with it. I called Dietary and told them what had happened, and ordered him a new sandwich, absolutely dairy-free. I filled out an incident report sheet. I waited by the room for his meal to arrive, and I inspected it like I thought somebody might be smuggling drugs inside it.

Once it passed muster, I brought it to him, and he demolished it. I have never seen someone eat a sandwich with such shameless delight. He wasn’t nauseated at all, had no stomach pain, and after eating it he grinned ear to ear and declared it to be naptime.

I went out in the hallway and charted and took a few deep breaths, shaken by the near miss, and disappointed in myself for the few seconds’ temptation to let Wishbone be poisoned again.

But what the fuck, man. We’re all kind of apathetic, one way or another. The entire history of humanity, all our bright points have been places where we didn’t do the easy thing. The dark places haven’t been just the shadows of truly evil people—they’ve been long stretches of apathy, or of power maintained by exploiting that apathy. The vast majority of human suffering has resulted from people like me, people with a couple of discharges to get moving, people who smell ranch dressing and are tempted to let it slide just this once, even though we know.

Jeeze. I wonder, honestly, how many times I’ve fucked up and really hurt someone just by being a little lazy. Just a little. Shit like that keeps me on my toes.

Anyway, after that Wishbone was seriously motivated. His pain was still tremendous, and his body remained under heinous stress, but as we tapered off the steroids and his body started to recover, Wishbone found a new advantage.

It’s not easy to exercise, full stop. Like, I have no physical disabilities besides a mild case of nearsightedness and a vaguely bum knee, and the only exercise I get is lifting pts and performing CPR. Wishbone, however, despite debilitating pain and weakness, got his ass out of bed every chance he got, leaning on the cardiac walker (a tall padded walker you prop your elbows on), and walked as far as he could.

This is a big deal. I’ve talked about the importance of mobility before, but for Wishbone it was his secret weapon. He pushed his body so hard that his nurses had to remind him, over the next week, that exhaustion would be detrimental and he needed to leave himself some reserves. Each pain medication gave him enough time, pain-free, to stretch his legs or practice his deep breathing.

We gave him antibiotics, fluids, procedures, therapy—all the things he couldn’t do for himself. But Wishbone earned his way out of the hospital, and walked to the wheelchair that rolled him off the ICU for home.

He was a pretty rad dude. I’m glad he turned out okay. His ileostomy is due to be closed and his intestines re-attached sometime in the next few months. I hope things go well for him.

Meanwhile, I don’t remember if I told you guys about Crowbarrens, and I’m too lazy to re-read my own blog (and also self-conscious and I hate my own writing). He was out for a while, and we were all worried sick about him. Yes, worried about Crowbarrens.

Remember, the last time we saw him, his wife had threatened to kill him. Having him suddenly go missing for two months was genuinely not a good sign.

Then he came back. His wife claimed that he had been coughing up blood, earning him a spot in our negative-pressure isolation room for a day while we ruled out tuberculosis, which should have annoyed the crap out of him—he hates to even have the door to his room closed, because that keeps him from shouting at staff as they pass by.

He didn’t comment. He didn’t shout at all. We inflated the cuff on his trach, and he tolerated it just fine, asked to have it deflated for meals, let us brush his teeth and inflate it again afterward. He looked a little distant, distracted. He watched TV in silence and didn’t even complain during turns.

Needless today, we got him a CT scan stat. Something was wrong in there, even if the CT scan came back clean, and they took him down for an MRI later that day—mind you, not on any clinical findings, just on the fact that he wasn’t swinging punches at people.

While we waited for the results, Crowbarrens threw up a bellyful of blood. Turns out, he wasn’t coughing it up, he was vomiting it up. A quick EGD later, a biopsy sample sent to the lab, and we had our answer: Crowbarrens was being nice because he was really, really sick.

Crowbarrens has stomach cancer.

I mean, he’s been an asshole, this doesn’t change that. After a couple more visits and some medication and treatment, he was right back to screaming and demanding and verbally abusing his wife, although he hasn’t quite got back the gumption to swing at us. But man, when it comes to getting the short end of the stick, Crowbarrens not only has a terrible neurodegenerative disease, now he’s got fucking stomach cancer. It’s like life can’t help shitting on the dude. I wonder who he would have been, with his awesome name and his devoted wife, if things had gone a little differently with his body and his life.

Meanwhile, my coworker Leah recently went through an unexpected and thoroughly shitty breakup. I worried a lot about her—she had always seemed quiet and very conscious of others’ opinions—but since the split, the whole unit has seen her sort of… become a much louder, less apologetic version of the person she is. We’re all glad the asshole ex is gone, but we also kind of generally hoped that karma would kick in and provide us with some entertainment.

The ex got a new roommate, a laaaaaaaady roommate. A single lady roommate. A single lady roommate with… uh… a cat. And she left the cat there and went out of town. This is sounding less reboundish by the second, right?

It gets better. The cat was an impulse rescue. It has fleas. A week after its arrival and apparent abandonment by the single lady roommate, the cat has imbued the ex’s entire apartment with fleas.

The ex has fleas now. In his beard. He has beard fleas.

He has fleas that live IN HIS BEARD.


This is all I could have asked for, karma. Thank you. We’re even now.

6 comments:

  1. Holy shit Elise, you're amazing. From explaining why steroids are bad for you, to pointing out why it's called epinephrine, you teach so clearly and awesomely. We need a book, "Elise explains medical stuff in ways anyone can understand".

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  2. Thank you so much for your honest and important discussion of apathy affecting even the best of us. It's something we don't talk about and need to talk about more. I've been shocked at the ways I find myself getting complacent and apathetic the more I get used to nursing. Being honest and open about it probably helps to keep it in check; thank you for that!

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  3. Horrifying and fascinating story about the consequences of dairy allergy; I became allergic as an adult and had to work out what was going on myself through elimination due to disinterest from my GP when it turned out not to be lactose intolerance. I'm sick of arguing with people that I don't mean "lack toast" intolerant, and I just don't eat anything if I don't recognise what it is or can't read a label for ingredients. And I became sensitised to soy as well after trying to switch away from dairy milk. I wonder if this happened with Wishbone too and the poisoning was accidental. I sometimes have been testing new foods by just eating a little bit and seeing if it makes me shit blood but I am never going to risk that again knowing a bit more about how badly this can go wrong. Thanks Elise!

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  4. private! U think you didn't anonymize all the way. Wieciezk instead of wishbone - paragraph 9 or so. Get that outta there!I enjoy your writing but cya!
    Vic

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    1. No worries, "Wishbone" is a nickname for Wiecziek the way his actual nickname was related to his actual last name (which was something totally different). Thus the asterisk after the first instance of his made-up last name!

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  5. Having had to spend time in the ICU of the hospital where I work because someone thought "I'm allergic to this thing" meant "I don't like this because I'm snooty", I want to go eviscerate the asshat who poisoned Wishbone. Preferably with something dull and rusty.

    Thank you for kicking ass, Elise. That weird moment of apathy? That's the monkey part of the brain that likes to see shit get flung against a wall. Good on you for squashing that fucker. Never doubt that you're a fabulous nurse, because you are. freaking. amazing.

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