Week 9 Shift 1

I showed up late for work by about five minutes, having lost track of time while I was standing in the shower performing my usual morning devotional of cursing, groaning, and ordering myself grimly to wake up, come on, you can do it.

Any time I’m late to work I sort of creep in from the staff elevators and try to sidle up behind the group report cluster without being seen. No luck this time—a bright-faced unfamiliar nurse called out: “You must be Elise!”

Turns out I was precepting today. Okay. Surprise?

Maycee has moved on to another preceptor—each new nurse gets two days with each preceptor, to make sure they get a good variety of teaching methods. I like precepting and am pretty good at it, but everyone learns differently, and I have precepted more than one person who wasn’t really meshing with my style and needed someone a little more methodical and hands-on. Today I would be precepting Anne, who loves airplanes and hiking and pictures of gross wounds, and who was very patient while I poured half a carton of milk into a cup of ditchwater coffee from the supply room dispenser, then thousand-yard-stared my way through the first half of it before my brain came back online.

Our pt was a tall, strikingly pretty older woman who had been very active and independent before she fell last night, smacked her head on something, and developed a huge head bleed—a subdural hematoma. There are several different types of common head bleed, and this is not usually the deadliest, but an SDH can really wreck your shit.

Week 8 Shift 1

By the time I got back, my DKA/wannabe escapee guy had not escaped, but had made everyone on the unit so angry they wished he would. His nonstop bitching and creepy remarks, combined with his gross treatment of his girlfriend and his frequent not-jokes about how we should just let him shoot up because he was going to anyway, had really not endeared him to any of the staff.

When I arrived, he smirked at me, then informed me that he would be leaving at 0930 whether I wanted him to or not, and if I had any shit left to do for him I better get it done in a hurry. And that he would have a long list of breakfast foods from the cafeteria, but didn’t want to stay on the line and wait to order, so he would just tell me and I would have to call down and order for him. When I told him he could either order his breakfast or go hungry, he shrugged. “Fine,” he said. “I have my own insulin, I’ll give myself a dose and go into hypoglycemia, and you’ll get fired.”

I have honestly never had a pt so openly threaten to harm himself to manipulate me. “I’ll give you IV dextrose,” I said, “and your insulin will mysteriously go missing while you’re unconscious, and you’ll wake up just fine except you’ll be hungry. Here’s your phone, you decide if you want breakfast or not.” Then I went and reported all this to the charge nurse and documented it.

His girlfriend met me in the hallway a little later. I won’t tire you with the entire conversation—it was very long and wandering and difficult to listen to—but the gist of it seemed to be that she wanted to stay in the methadone program and get clean. If she stayed with him, she said, he would never let her get clean; but if she left him, who would take care of him?

“I think you’re right,” I said. “He’s gotta find his own rock bottom, and hope that it isn’t a grave. If you want to get better, you’re definitely going to have to get away from him, and you’re going to need some professional support while you’re remodeling your life.”

“But what if he dies?”

“Then he dies, chickadee. Maybe you won’t die too. When you’re drowning, you gotta kick off your shoes.”

I know there’s not much hope for her. But I really hope, if she dies of this, she’ll at least die without that asshole being rude to her the whole time.

At any rate, I got that dude’s discharge paperwork done in record time. I am already a lightning discharge nurse, which usually helps out my pts who really really want to get home in time for the game, but I had him ready to go by 9:15. I cornered the hospitalist that was seeing him and told her she could either give him discharge orders or sign his AMA*, that I had everything ready to go for him to leave, and that the only medical reason I could see to keep him was that he’d threatened to inject himself with insulin so I’d have to order his breakfast. We could have stretched that into a suicide threat, but honestly, it wasn’t. And there wasn’t much else we could do to help him.

(*AMA, in this case, has nothing to do with reddit—it just means Against Medical Advice.)

If I seem callous about this, know that I have zero interest in whether a person is addicted to a substance—it’s a disease we understand very little about, and one that destroys lives as ruthlessly as any sepsis or stroke. The mental health issues that so often accompany addiction, those I have even more sympathy for: my family is not without its comorbidities, and I have seen firsthand over many years the impact of addiction, bipolar disorder, major depression, personality disorders, and post-abuse trauma, all untreated and all devastating. I see this shit every day on the ICU, and it’s a parade of tragedies that never fails to make me sick with frustration that I can’t save them.

But there are, among the tragedies, people who victimize others in their tragedy. Just as it’s hard to feel fully sympathetic for a person who survived horrific childhood abuse and goes on to abuse their own children, it’s very difficult to feel that sympathy for a person whose lifestyle is so self-destructive and so poisonous that they won’t let their loved ones escape the same trap, and whose attitude toward the people they’re hurting and the people who care for them is one of loathing and snide gloating.

And there are people who are offered the help and support they need, and laugh at the people who offer and how disappointed they are when those gifts are refused.

Not a lot of sympathy, no. I was glad to see him go. He asked if he could keep his IV “for convenience.” I gave him an incredulous look and then “accidentally” pulled his IV out with one sharp yank.

“Oops,” I said. “Usually I leave those in until right before discharge. Oh well, you’re leaving soon anyway.”

He and his girlfriend sat in the room, rolling cigarettes from the tupperware of tobacco, until I escorted them to the door. On the way out he joked that maybe he’d offer me a ride in his truck sometime. I couldn’t even feign a farewell smile.

Meanwhile, next door, a coworker of mine landed a pt with Evans Syndrome, a rare autoimmune disease that causes your body to eat all its blood. The pt was acutely psychotic for some unknown reason and lay in bed screaming as if being burned with hot irons. Pain medication did nothing; anxiety medication helped. He couldn’t tolerate anything touching his body and ripped off his ECG leads and clothing constantly. We didn’t bother putting in a foley, but any time he needed to urinate, he would start screaming extra loud and rolling back and forth, cursing and wailing, until he finally let it all loose and soaked the bed/floor/wall/everything in the room.

The second time this happened, I was helping hold his legs down while he struggled to kick and bite the nurse, and the dam broke just as he started bucking. The ensuing arc of piss undulated across the room like one of those floppy-hose kids’ toys that squirts water at shrieking babies in the back yard. He got himself in the face pretty good, and it shut him up for a minute, his whole face contorting in puzzlement as he smacked his lips and snorted. Then he saw that he’d peed comprehensively all over the other nurse—he only got my arm a little—and started laughing hysterically until he passed out from more Ativan.

Meanwhile I had a second pt to take care of: a woman whose uterus had been removed earlier this year for cervical cancer, whose extensive internal scarring had formed massive adhesions and twisted her small intestines until pieces of them died. She’d undergone immediate surgery to resect the dead bowel, and been in pretty good shape afterward. Yesterday morning, however, she had become confused, then gone into respiratory distress. Early in her confused state, she’d pulled out her feeding tube, vomited, and possibly aspirated before finally being intubated and sedated. My job, today, was to support her through what could either be the return of bowel ischemia, or the beginning of ARDS.

She required lots of fluid support and plentiful pressors. She could hardly tolerate turns, and her urine output was minimal at first, though it picked up as we started Lasix to get rid of her sixteen liters of extra fluid. She was in Tiberius’s room, which felt very strange, because her family was also delightful and friendly and religious.

By midafternoon it was pretty obvious that she had ARDS. What’s more, her intestines started to pick up slack and give me some really gross noises, which is fantastic to hear in a pt whose guts are still stunned from massive injury and surgery. But man, that ARDS was not treating her well, and we kept cranking her fiO2 and PEEP up to keep her ventilated… and, eventually, oxygenated. It takes a lot for your lung tissues to stop exchanging oxygen well. We finally found a nice plateau at a whalloping PEEP of fourteen. (Five is the average. Ten is what you get when you’re ARDSy. Twelve is considered a bit much.)

The rest of the day was a matter of balancing her pressures with her body’s ability to tolerate pressors. Levophed made her arms and legs mottle deeply and turn icy cold, and didn’t have as much impact as I would have hoped on her blood pressure. The PEEP was making it hard for her heart to fill and squeeze effectively, which dumped her BP, which in turn made it difficult for her body to get rid of the excess fluid that had accumulated in her body.

There are three spaces in your body where fluid can hang out. Well, I mean, there are lots of places where fluid hangs out, but there are really only three we care about when we’re thinking about fluid overload and blood pressure.

One space is inside your cells. They’re just little water balloons, right? Some DNA and RNA and a mitochondria or two floating around in there, maybe some enzymes doing heavy lifting, some proteins grabbing shit and gluing it together… and, you know, water. This part is pretty boring to me unless a) my pt has been exposed to cyanide or b) my pt is going to need some kind of insulin fuckery to move sugar or potassium into their cells.

Another space, which I am HIGHLY obsessed with, is the vascular space—your actual bloodstream. Water, albumin to thicken the water and keep it osmotically the same as everything else, blood cells, dissolved gasses and sugars and shit… but mainly, blood pressure. Blood volume. If you’re bleeding out, the first thing I’ll give you won’t be blood, it’ll be saline; it’s the same salt concentration as your blood, and it will expand your blood volume so that the blood cells you have left can actually get around and your heart has something to pump.

Remember: if you ain’t got pressure, you ain’t got shit.

But there’s a third space: the areas between the cells, the structural nooks and crannies of the flesh. And when you’re massively inflamed, that space fills up. When your finger gets stung by a bee and swells up, you don’t suddenly get twice as many finger cells—rather, your inflamed cells call out for help, and your body responds by flooding the areas between them with water so that your white blood cells and antibodies can move around more easily and clean up the toxins. Your finger swells up.

When your whole body undergoes systemic inflammation, as with sepsis, that is a whoooooole lot of swelling. And all that water has to come from somewhere—namely, your vascular space. Pretty soon, there’s not enough water volume in your blood for your heart to circulate effectively, and your bloodstream is drying up, and your organs are dying for lack of blood flow while your body happily carries on dumping all its water into your puffy fingers like it’s gonna do any good there.

That’s the basic dynamic of sepsis. And this lady, with her aspiration pneumonia and her fucked-up guts, was septic as all hell. We had boosted her blood volume over and over with fluid boluses, and done our damnedest to pull the fluid back from her third space into her vascular space, but in the end all you can really do is try to interrupt the septic/inflammatory processes with antibiotics and other drugs, support their blood pressure with volume and pressors, and wait for them to pull out of it so you can dry them out again.

Thus, we gave her Lasix. Albumin first, to draw the fluid into her vascular space; then, after thirty minutes, Lasix to diurese her, to pee off the fluid so it didn't overload her struggling heart and increase the pressure and fluid drainage inside her lungs.

It was a long, exhausting afternoon, full of minutiae and sweating into my eyes. Her mottled flesh continued to spread, and her edema increased visibly from the beginning to the end of my time with her. I don't have a good feeling about her outcomes. I suspect she will never be stable again until she's dead.

Meanwhile, another crazy substance-abuse pt was admitted down the hall. I could hear him screaming and cursing even while I was turning my lady, and one of the other nurses poked her head in to ask if I still had the key to the velcro restraint box (I did not).

Things seem to come in waves on the ICU. We’ll get a bunch of STEMIs in a row, then a bunch of GIBs, then a bunch of ARDS. In reality, it’s probably just a normal distribution of all the shit that can go wrong in a decent-sized city; to the endlessly superstitious nurses on the ICU, it means that once you get two pts with similar symptoms, you are destined to get at least two more in the next week or so. This happens often enough to turn our confirmation bias into rock-solid religious conviction. Not looking forward to the next round of crazy.

But who knows? I could just be destined for admit after admit with stuck gut and sepsis. Or I could be too tired to think straight. I suspect the latter is more accurate. Time to pass out.

Week (actually) 5 Shift 1

This facility starts its weeks on Mondays. So I typically work Fri, Sat, Sun, Mon; have Tues off; work Wed & Thurs; then have seven days off in a row. It's a pretty rad schedule.

Report this morning: one charming lady with restless leg syndrome and chronic GERD, who had come into the ER after the most severe heartburn of her life, only to discover that she was having a STEMI.

The term “heart attack” is kind of tricky. We picture a guy grabbing his chest and keeling over, or if the TV writers are extra clever, maybe the guy has some left shoulder pain and starts sweating. The medics hook the actor up to a monitor and we see a flat line—his heart stopped! OH MY VERY FUCK, WE HAVE TO SHOCK. The nurse and doctor make eyes at each other as they paddle one million kilojoules into the patient’s nipples.

This may shock you: heart attacks on television are not usually accurately portrayed. For one thing, if your heart has stopped, you are generally not gonna have the energy to clutch your chest and manfully pretend that you’re just a little out of breath. Heart attacks—we call them myocardial infarctions because that sounds more professional and cool—may often end with cardiac arrest, but kind of in the same way that digestion ends with pooping.

“Myocardial” breaks down into two words: cardiac, which I’m sure you can figure out, and myo, which just means ‘muscle tissue’. Infarct is not a word we use often in the civilian world, although we fucking should, because it means that something has necrosed from oxygen starvation. “What happened to your boss?” “He has been… infarcted.” So myocardial infarction, MI, means that blood flow to part of the heart has been cut off, and some of the tissue has died.

The surrounding tissue is typically ischemic, which is another great metaphor word that should totally be used to describe shit like traffic jams, social isolation, and wi-fi shortage. Ischemia means that the tissue is being starved for oxygen, but hasn’t actually died yet. So in any MI, there’s usually an area of ischemia that can be rescued if you get blood flow going again.

Ischemia is responsible for the pain. Dead tissue doesn’t feel like anything much, but injured and starving tissue does. If you’ve ever sat on your leg wrong and cut off blood flow to your foot, you know how much that shit hurts. Or if you’ve attempted to run a mile because you heard it’s a good thing to do, and ended up a block and a half later throwing up into your neighbor’s hydrangeas while your diaphragm insists that it’s been stabbed in the dick—which is absolutely not something I would do of course—you know what muscle feels like when it’s pushed past its ability to gather oxygen.

Weirdly enough, biologically female bodies have different symptoms. I’ve heard various rationales for this, ranging from “smaller blood vessels” to “different enervation” to “estrogen causes clotting changes” to “uhhhh lady parts are weird.” Fact is, if you were born with a vagina, chances are good your heart attack will feel more like back pain, indigestion, fatigue, and shortness of breath than the “classic” heart attack. (This scares me, because I don’t know about you ladies, but I just call that Wednesday evening.)

I would like to see some more research done on heart disease and MI symptoms in FTM transgendered people undergoing testosterone therapy, by the way. I feel like we could learn a hell of a lot about the effect of androgens on the cardiovascular system.

But I digress. The area of ischemia and infarction is really important. If there’s just ischemia, no infarct, you get angina—transient (or not so transient) chest pain that isn’t a heart attack, but should warn you that you’re in danger. If there is infarct, but only some unimportant corner of your heart muscle dies, you can still have some nasty side effects (any dead tissue, for instance, is at risk of rupturing), but you’ll probably be okay except for the loss of heart flexibility and contraction power.

If you have a chunk of dead heart in the middle of a crucial conduction path or an area responsible for a lot of fluid-pushing, you are in serious, serious shit. The bigger the MI, the more likely you are to kill off a really critical section of your heart, and the more vital it is that you get the clots dug out of your heart , like, stat.

One of the ways we tell the gravity of the dead-heart-chunk situation is by classifying MIs as NSTE-MIs or STE-MIs. A Non ST Elevation MI typically has an area, the ST segment, in the EKG—the wavy line that represents electrical activity in the heart—that is depressed, rather than elevated. The depressed line tells us that the electricity is moving slower in that area of the heart, because the cells are stressed out and can’t exchange ions quickly (remember how some ions, like potassium, belong inside the cell, where they provide electrical impulse?). If the cells die, however, they stop being machines and become dead lumps of cell-wreckage, with ions floating around their battered husks freely. And this means that transmission of electrical impulses through that area is extremely fast, because nothing is regulating the flow, because everything is dead and therefore isn’t accessing (or even delaying) that electrical signal before it’s passed on to the next glob of cells.

This is expressed on the EKG as an area of ST elevation. An ST Elevation MI is bad, bad news, and requires immediate intervention and clotbusting. An NSTEMI can often be medically managed for a while with oxygen and anti-clotting medications and vasodilators to increase blood flow, allowing the body a chance to fix its shit without having holes punched in it. A STEMI is do or die—punch a hole in the pt’s crotch, jam a long tube up their femoral artery and aorta into their heart, dig out the clot, and put in a stent to hold the chewed-up cardiac artery open before any more heart-chunks die.

The weird thing is that, after a cardiac cath procedure, pts often don’t realize how big of a deal this is. They were moderately sedated during the procedure, and there wasn’t a lot of visible cutting, and their chest pain is all better and they’re annoyed because they have to keep their leg perfectly straight while their femoral artery heals for a few hours. All the cousins visit and bring flowers and See’s Candies. They’ll be headed home tomorrow or the day after, gotta pick up a few new prescriptions on the way, remember to call 911 for chest pain or shortness of breath, back on their feet in time to make that baseball game on Friday. It’s not like they were dying.

And yet… they did almost die. Twenty years or so ago, before we had cardiac catheterization as an option, people keeled over and died all the damn time, and even if they made it to the hospital there wasn’t a thing we could do. STEMI or NSTEMI, we dumped medications into them and crossed our fingers that enough heart muscle would survive to keep them going. They would lie in hospital beds, pale and sweating and gasping for breath, gagging on ten-out-of-ten crushing chest pain, until the MI had run its course and they could either go home and wait to die slowly of heart failure, or half their heart turned black and gooey and they died. For days.

Modern medicine is nothing short of a fucking miracle.

Anyway. All that was to say: this pt was absolutely just fine, headed for home by noon the next day, eating and walking around. She was a good pairing for the other pt I picked up.

My other pt was incredibly sick. He had been some kind of college athlete once upon a time, headed for the big leagues, scouts bothering him while he and his brand-new wife tried to move into their brand-new home. Then he was diagnosed with non-Hodgkins lymphoma, dosed with chemo, nuked with radiation, sliced open to remove his spleen, and finally proclaimed cancer-free. He played his sport the entire time, but after college his health—while fairly acceptable— wouldn’t permit professional athleticism. He still holds several records at his prestigious university.

Fast-forward a couple of decades and a couple dozen hospital stays. The radiation tore him up. His esophagus was burned and scarred, and where his spleen had been removed to stop the spread of lymphoma, he now has a hiatal hernia—a weak spot in his diaphragm—and his stomach has adhered to his belly wall. He’s had a couple of heart attacks, as his coronary arteries were so damaged by the radiation that they’re all scarred up and tear and clot easily. And recently, he started coughing up blood.

A biopsy revealed adenocarcinoma—cancer, from the radiation that once cured him of cancer. His left lung was eaten up with it.

About a week ago, he had surgery to remove the cancer. They ended up removing his entire left lung and pieces of the pericardium, the fluid sac around the heart. The tumor had grown to wrap around the pulmonary artery, which made the procedure a terrifying ordeal—a millimeter off, and the pt would exsanguinate like the Black Knight. While they were removing his lung, he suffered another MI intraoperatively, and because of the severity of the surgery and the danger of fucking up his precariously snipped-and-scraped pulmonary artery, they weren’t able to perform a cardiac cath for three days.

It was a STEMI. The right side of his heart, the side that pumps blood into the lungs (or, in his case, lung), has lost some of its function permanently.

But after the cath, he started to come around. He was extubated, and managed to talk and sit up in a chair and even have a few sips of water, although his esophageal scarring had acted up again and he had developed stenosis—narrowing—which prevented him from eating.

A few days later, he vomited. He inhaled the vomit. Things went downhill from there.

A lot of people who vomit while already weak or ill accidentally inhale it. This is incredibly bad for the lungs and can cause severe pneumonia, both from the germ content of the gut juices and from the irritation of stomach acid in the lung’s air sacs. For him, the combination of slow gut movement (after anesthesia and opioid administration, a very common effect), esophageal scarring, and adhesion of the stomach caused vomiting, and his body’s weakness combined with his scarred-up throat kept him from protecting his airway. Within twelve hours, he was reintubated.

Attempts to give him a feeding tube failed. Even in Interventional Radiology, where live-action xray imaging is used to do delicate internal work, the tube wouldn’t go the right way. Important medications, like the Plavix he takes to keep his cardiac stents open, went unadministered; other drugs, like heparin, provided some protection but still left him at uncomfortably high risk. His depression medication levels lagged.

I picked him up, noted that he was pouring gross green-gray chunky secretions from his remaining lung, and alerted the pulmonologist. I’ve seen pts cough up some outrageous things, but this looked like some kind of dead flesh liquefaction business, and smelled like fish sauce. The pulmonologist grabbed a bronchoscope and a respiratory tech, and we did a bedside swish-and-slurp of his airway, sending the results off to be examined by the lab.

There really wasn’t much down there, reported the pulmonologist, just a big chunk of sticky gray shit—which came up through suction in pieces, a chunk maybe the size of a cherry pit all told, reeking like an Icelandic delicacy—and a lot of very irritated lung tissue. We did a chest x-ray, and revealed patchy white spots that indicated fluid buildup in the lungs. The pulmonologist suspected pulmonary edema, and ordered a diuretic to see if that helped his lungs clear out… but I suspected something grimmer.

Pulmonary edema—backed-up fluid in the lung tissues—typically happens because the left side of the heart is sick and can’t pump fluid away from the lungs effectively. It’s not uncommon after a left-sided MI. But this guy had a right-sided MI, so if there was a fluid back-up issue from the heart, it should be backing up into the tissues themselves, not into the lungs.

There is another condition that looks like pulmonary edema, and is, in a way, fluid swelling in the lungs. It’s called ARDS—acute respiratory distress syndrome—and instead of fluid pooling in the air sacs, the lung tissues themselves become inflamed and brittle and start to weep. The cardboard-stiff tissues are too swollen to allow blood to flow easily, and fluid backs up into the right side of the heart, blowing it up like a balloon, and causing atrial fibrillation as the nerve fibers stretch apart and start panicking and firing at random intervals.

ARDS is not a thing you want to have with only one lung.

By midmorning we performed another bronchoscopy, this one attempting to advance his breathing tube past the split between his airway branch, the place where the left and right mainstem bronchi split, called the carina. If we could get the inflatable balloon cuff down into the right mainstem, totally cutting off the left, we could increase his PEEP, forcing some of the fluid back into his circulatory system and protecting his air sacs (alveoli) from boogering shut. (Increasing the air pressure against a freshly sewn-up bronchial tube is a bad thing, and can cause rupture, which is basically the worst.)

In the end, we weren’t able to get the cuff secured in the right mainstem, and he continued to struggle to oxygenate and ventilate. Finally, in fear and trembling, we raised his PEEP juuuust a little bit.

And what do you know, he improved! Finally a fucking break for this guy.

He was improved enough that the GI doc felt safe doing a bedside EGD to try and place a PEG tube for feedings. Unfortunately, between his hiatal hernia (stomach not where it should be), his esophageal stricture, and the adhesions, the only place that was available to stick a tube through would have gone through the wall where all the arteries are. You can imagine how excited we were at the prospect of blindly cutting into a forest of arteries on this guy. Instead, the GI doc fed a small-bore feeding tube along the scope, and just like that we had access for his pills again. Not a moment too soon—his anxiety when he woke up was out the roof. I ended up grinding a Xanax into powder and flushing that down his feeding tube.

Oh yeah—this guy is poorly sedated. We have him on a shitload of fentanyl for pain, but his hospital course has been long and ugly, and opioids don’t work as well for him as they used to. We’re also using precedex, a newer sedative that’s not supposed to contribute to delirium or cause hypotension, but which the average ICU nurse will tell you is almost as effective as plain saline at sedating a really agitated pt. I asked if we could start him on some propofol, and got some bullshit about the danger of prolonging his QT interval—the time it takes his heart to repolarize and be ready for the next beat—even though we have him on a kajillion other QT-prolonging meds. I just bolus him a huge dose of fentanyl every time I plan to do anything to him, and dosing him with all the grudgingly-metered benzos and low-level pain control meds (tylenol, toradol) I can scare up by jumping out at doctors from behind the printer.

His nausea issues have been a fucking thorn in my side. With his guts all backed up, he can totally puke around the breathing tube, although his airway will be protected… but a newish surgical incision is not a fun thing to strain against while you’re vomiting. Also, I am not a fan of all the pressure jackery that comes along with dry heaving, especially with that left mainstem all delicate. I’ve been giving him a ball-ton of Zofran, which usually helps with the nausea… but it’s not doing a lot. The docs have me giving him scheduled Reglan, which stimulates gastric movement and reduces nausea, but it doesn’t seem to be very helpful, and has the potential to interact with his SSRI (as would any of the stronger anti-nausea meds). I’m giving him some truly thorough oral care, for the most part, and trying to avoid stimulating his gag reflex any more than I have to.

In the midst of all this, I traded pts at 1500 during afternoon shift change. Somebody else got my lovely STEMI lady, and I picked up a complete train wreck of a family whose grandfather has been treated uselessly for glioblastoma, a brain tumor that has negligible survival rates. They’ve put him through everything anyway—chemo, gamma knife, you name it. He’s slowly losing control of his body. His family is of mixed faith, mostly Farsi speaking, and the faith conflict has been… incredibly tricky. As a result, he’s just lying in the ICU slowly choking on his secretions while the family fusses about him, providing tons of supportive care and love and also fucking with all his equipment and doing batshit crazy things like stuffing his oxygen mask straps with tissue paper to keep the loose elastic from irritating his face. All the air whooshes out over his forehead and he starts gasping, so they plug the edges of the mask with more tissue paper. I walked in there about 1700 and thought that poor fucker had been mummified. They had also poured medicated antifungal powder all over his body, patting it into his thick pelt of body hair until he looked like some kind of gigantic Versailles pompadour or a guinea pig making a nest in a brick of cocaine.

At one point I walked in and found three of them crowded at the foot of the bed, fighting with each other about God and about whose caregiving was the best as they clipped and filed his toenails, which were grisly. I backed out of the room and left them to it.

Their behavior is just fucking bizarre. They fight and snivel and guilt-trip each other and assume martyred postures and heave endless rubbery sighs as they make up new and ever-more-intrusive ways to take care of their grandfather, who looks more and more uncomfortable as they tape towels to his hands and smear vaseline in his eyebrows and fiddle with his foley catheter so that it pulls against this side, then the other side, then this side again, of his urethra.

Apparently a number of nurses have fired them. I am well-accustomed to families from that part of the world being very involved in pt care, distrustful of American doctors, and deeply invested in the possibility of their family member recovering even when chances are slim. That can be challenging, because American medicine is not really set up to accommodate that spectrum of cultural needs, and anybody who’s worked in a hospital can tell you that pts with a thick accent are more likely overall to have their questions and requests ignored. But it’s not really something to fire a pt for—it’s something to learn a new cultural language for.

This is totally different. These people are an unhealthy family of whackjobs with irreconcilable differences who are held together entirely by the tenuous glue of their grandfather’s chronic illness, which they use against each other as a weapon, struggling to maintain control of his condition by being the most caretaker at any given point. His body is a family battleground. Thank goodness he’s mostly zonked and doesn’t have to be awake for this bullshit.

Abd guy has been making tenuous progress. His abdomen is mostly closed except for a wound vac, and he was able to wake up during my camping trip and follow commands. As far as I can tell, nobody has checked him for methanol intoxication yet. I floated a hint to his nurse, although I’m not sure at this point it will make much of a difference. His anion gap acidosis rages unchecked. I’m impressed that he’s alive, let alone progressing; his necrotizing pancreatitis is severe. I’m not exactly holding out a lot of hope for him, but who knows?

If I had to choose only one of them to survive, I'd rather see my pneumonectomy guy live than my abd pt, which makes me feel a little guilty. They both seem like nice people, but the abd guy is a single dude with a distant family—still ignorant of his condition, none of them in contact yet—and a crippling chronic addiction problem that will make his recovery process hell for him, while the pneumo guy is just an unlucky dude who got cancer as a young adult and who has kids and a wife who will be devastated when he’s gone.

But hey, if I could choose who lives or dies, I’d throw Crowbarrens out a window and chuck his wife after him and let both of these guys live. I would be a dread god of capricious benevolence.

Crowbarrens isn’t back yet, and every day he stays gone, I’m a little more antsy. I can’t believe we sent him home last time with his wife—did I mention this? She brought him in on a Friday because all their daytime home health nurses were taking the weekend off and his wife, who performs all care for him at night and while the caretakers are gone, called the police and said that if she had to spend the weekend with him she would murder him and then kill herself. She spent the weekend on our psych unit and he spent the weekend on our ICU. AND THEN WE SENT HIM HOME WITH HER. That will go over really, really well if she actually does murder him. Or if there’s a welfare check and he tells the police what she said last time. Or, basically, if anything happens to him at all, we are getting reamed like half a lemon by Adult Protective Services.

I cornered my manager and delivered a frothy screed about risk management and liability and the extent to which I do not want to lose my job because the ICU got sued down to the baseboards and is now too poor for indoor plumbing. His eyes bugged out a little bit. I think this is the first time he’s seen me in warpaint. It’s good for him, probably. I hope he doesn’t start dodging me behind corners.

Three days on, then one day off, then two more days on. Then I go camping again, because I have a Problem.

God, I hope this one lives. He probably won’t, but I hope he does.

Week ???? Shift ???????????

Some things I forgot to mention last time:

At 1100, shortly after I received the abdomen pt, I called up the charge nurse and politely requested to have him made 1:1. I don't ask for this often, and pride myself on my ability to balance multiple high-acuity pts safely. But part of this ability involves my recognition of when the load is too heavy for safety-- anyone can pretend they have things under control right up until a pt codes-- and when I realized this pt had hourly insulin checks, constant potassium replacements from an electrolyte replacement protocol (the intensivist declined to start a potassium-containing IV fluid despite refractory K+ levels below 2.8, the cutoff point below which the heart starts to starve and freak out, on the grounds that his renal failure would cause his K+ to skyrocket eventually), q2h labs, and 200mL+ output every hour from his NG tube (thus the potassium loss: stomach juices contain a lot of K+)... I had also just started levophed to pull his blood pressure up, couldn't find peripheral pulses in his feet, and was calling the RT in frequently to handle his ventilator-bucking. Yeah, at this point I decided he wasn’t going to be compatible with the high-need lady next door on bipap, no matter how clean she was now.

I was pretty sure he’d code by mid-afternoon.

The charge nurse came in, looked around, and agreed with me. So after 1100 he was 1:1. This came in really handy when the GI surgeon took him down for that washout.

So for the next couple of days, he wore me out. His open abdomen wept constantly through the drains in the intestine-containment bag, and every thirty minutes he required a full dressing change just to control the flow. His insulin infusion had to be cranked up from one algorithm to the next, as higher and higher doses failed to control his wild hyperglycemia. Worse, as I finally caught up on his blood sugars the next morning, his anion gap stayed wide open—the acidosis continued, and although his potassium finally caught up and began to rise as his small bowel obstruction stopped backing four liters of stomach juices out of his NG tube every day, the problem was clearly not a sugar/insulin imbalance.

Anion gap acidosis has a number of possible sources, although insulin deficiency is probably the most common. A few of them were addressed in that nephrologist’s note I quoted the other day. Another occurred to me during my camping trip this weekend, as I was studying for the CCRN test I took today (AND FUCKING PASSED YESSSS I AM A CCRN NOW). This guy is an alcoholic, and had been sick for a little while, homebound. What if he got into some alcohol that wasn’t drinkable? Specifically, methanol? It would explain some other major things, like the encephalopathy and his eventual failure to maintain pupillary reflexes.

Man I got no idea. I haven’t actually taken care of a pt with methanol poisoning, so all my knowledge is book knowledge. Methanol, aka wood alcohol, is an alcohol much like ethanol (booze), except that it turns into formic acid in your body, destroys your eyesight permanently, causes brain swelling, and tends to result in horrible death. I’ll have to look that up when I get back to work on Saturday.

Anyway. He stayed very high-acuity for the next few days; I was 1:1 with him the next day, and the day after that I was first admit, but ended up not admitting because the only person who came up from the ER was a telemetry overflow. He was one of those pts who isn’t panic-level crazy, but whose workload nurses describe to each other as “steady.” Basically, there’s something to do at least once every ten minutes, some of these things taking as long as twenty or thirty minutes and requiring multiple RNs or the help of a CNA, and you spend very little time charting because you’re constantly scanning medications or taking blood sugars or turning or changing dressings or titrating drips.

In this case, about halfway through the second day, the intensivist ordered lactulose enemas to be given every four hours, in hopes of stimulating his bowel to move. I took extreme issue with this because I could SEE the guy’s intestines and they were obviously too swollen to twitch, let alone move stool effectively, but considering that his colon was relatively un-irritated per report of the GI surgeon and the enemas were only about 250mL volume (we often give 1L-2L enemas!), I figured it couldn’t hurt. And sure enough, after the second enema he dumped a decent handful of mucoid stool, although his small intestines were obviously still not moving.

How did we administer these enemas? The traditional way involves turning your pt on their left side, sticking a tube up their rectum, and draining a bag of fluid into their butt to get the shitslide cookin’. Turning this guy onto his left side would have been… tricky, so instead I pulled the rubber tube off the business end of a foley catheter, lubed it up a bit, jammed it up his butt via the “lift balls, grope for anus” method, and inflated the balloon with a syringe of saline. Then I mixed up the enema, drew it up into a giant Toomey syringe of the kind we use to instill fluids into a GI tube (it holds about 60mL at a time), and flushed it all through the rubber hose into his colon. Between flushes I clamped it off with a large hemostat, the kind we use to clamp chest tubes shut. An hour or two later he dumped the full enema, still clear, into the bed. Time to start over.

Turning was tricky. Any time we moved him, he would grimace and his blood pressure would skyrocket—even though he was heavily sedated and receiving a pain med drip, he was clearly having a lot of breakthrough pain. His blood pressure tended to run dangerously low whenever he wasn’t in pain, though. So I would dose him with a huge bolus of fentanyl, wait about two minutes for it to kick in, watch his blood pressure start to bomb (watching in real time through an arterial line), and then do all the turning and washing and dressing changing and whatnot.

Ventilated pts also get their teeth brushed or their mouths swabbed and suctioned once every two hours, usually right before we turn them so there isn’t a drool river when we’re moving them around every two hours. 

The whole time, we were hunting desperately for someone to make decisions on his behalf: a family member, a designated power of attorney, anybody. His kidneys weren’t pulling out of their tailspin, and the buildup of nitrogenous wastes in his body wasn’t doing him any favors. Before we made the huge step of initiating dialysis, though, knowing that this would be a long healing process with a huge amount of involved and intensive care, it would have been really nice to know if he’d have wanted it.

This being a weekend, and this fellow being a member of a specific healthcare group that has its own social workers and discharge nurses that aren’t available on weekends for whatever goddamn reason, I found myself doing most of the work of contact hunting. I called his job and, without being able to give them any details over the phone, asked if he had any next-of-kin numbers. None of them worked. I called his home phone, got his roommate, learned that he had a daughter he had only ever referred to as “my daughter;” received a phone call from a coworker of his who had heard he was out sick, and found out that he has a landlady who “might know somebody;” called the landlady and learned that he had family somewhere in a Middle Eastern country “who don’t speak any English and I don’t know their names;” and was finally suggested to contact a religious leader of his community, who might have access to lineage papers.

By the time I got to that point, it was Monday morning, and the social workers were back on the job. So I spent about an hour pushing them over the phone, giving them a full report of everything I’d done to seek contact, and signed off on his “call the family” duties.

Meanwhile, down the hallway, the drowned kid circled the drain for days. His lungs were torn to shreds by the lake water; his anoxic brain injury caused him to start seizing for hours at a time; his mother went completely insane before my eyes and descended from “horrified and grieving mother” to “crazy woman in filthy clothing laugh-sobbing in the end of the hallway all day and all night.” God, we all felt terrible for her. She threw a shoe at the palliative care people when they came by. 

He went into a rotoprone bed, as I think I said before, and coded in it. A rotoprone bed is no minor thing in ICU practice. It’s like a huge padded coffin/cradle into which a pt can be packed, then wrapped tightly in cushions and panels and straps, then rotated until their face is hanging downward so their lungs can drain. Once they’re proned, we open the back of the bed and let them lie there, gently swinging back and forth with their belly facing the floor, letting their lungs stretch and drain and slowly recover. It’s very effective when used early, and was originally marketed for H1N1 support, since young pts who survived the initial respiratory catastrophe of that strain would recover easily enough in a week or two.

Now we use it for ARDS, acute respiratory distress syndrome, which can happen for many reasons ranging from pneumonia to aspiration to pancreatitis. In ARDS, the lungs become so inflamed that their tissues turn thin and stiff, they can’t exchange gas well, fluids weep into the air sacs, and even the blood vessels lose their pliancy and become hard and resistant to blood flow. 

We use a lot of things to treat ARDS. Paralytics can help reduce the pt’s inclination to fight the ventilator, and minimize their oxygen usage; Flolan (epoprostenol) is a ruinously expensive inhaled medication that dilates the blood vessels of the lungs to allow improved blood flow; chest physiotherapy can sometimes be used to help break up secretions and move fluids around; and, of course, antibiotics and steroids and protective settings on the ventilator to prevent lung damage. And PEEP.

Remember how a bipap mask adds a kick of pressurized air at the end of the breathing cycle to keep the airways (large and small) open? PEEP (positive end-expiratory pressure) is similar to that. Cranking up the pressure helps force fluid back into the veins, keeps the air sacs open, and increases the pressure gradient of air vs blood so that air exchanges more effectively across the membranes. Usually ventilation (CO2 shedding) is harder than oxygenation, but in ARDS pts often have oxygenation just as bad as their ventilation. 

I’ve seen ARDS fought effectively. I cared for a pt once who was very young, got a nasty pneumonia, spent days and days in the rotoprone bed, and was eventually transferred to the local children’s hospital to receive ECMO—extracorporeal membranous oxygenation, in which blood is drained from the body, oxygenated through a membrane, and pumped back into the body constantly. She ended up doing well, and sent us a letter about a year later to let us know that she had not only survived, she had recovered enough to walk across the stage at her graduation.

The drowned kid will not be so lucky. Even if his lungs manage to recover from the lake water problem, his brain is completely fucked from the continued hypoxia. We are, essentially, buying the family time to say goodbye.

Which is a victory, sometimes. If we define death as failure and any kind of life as success, then pretty soon our successes are often hollow—we have quite a few pts who end up suffering for a very long time and being shipped back and forth between the hospital and a long-term acute care facility—and our failures are nearly constant.

You have to look for other definitions of success and failure, here. Sometimes our victories are good deaths. Sometimes we work our asses off day and night to make sure a pt is comfortable as they’re dying. Sometimes we finally manage to talk the family into letting go; sometimes we struggle to win them the few days they need to come to terms with their loss. Sometimes we squeeze enough time to let the plane land and the taxi speed from the airport, so that the kids can be there when their father dies. Sometimes we wash our hands of a code and catch our breaths, and the corpse cools in the room while we go back over the entire crisis and realize that we did everything right and they died anyway. But it’s still a victory, just as all these others are victories: we did everything right.

But they died anyway.

And sometimes we practice our skills on a pt who has made every possible bad choice and is dying of their bad choices, knowing that our care is futile and the resources we spend are wasted, but knowing that when the next pt comes in needing that unusual procedure, we will be that much fresher in our practice. That’s a victory, if you squint.

And sometimes we fight tooth and nail to save them, and care about them, and care so deeply about their survival that when they die anyway we are all devastated and we go out and drink and wish we could have done anything, one more thing, to save them. Which, I don’t know, might not be a victory; but it feels like something more important than a defeat. It feels like a connection. It feels like we have successfully recovered our humanity, which we often hang on the break room wall next to the memo notice sheets and the spare stethoscopes, so that we can dig in a pt’s guts without cringing and accept verbal abuse without snapping and look death straight in the face without blanching. It’s inconvenient, but it’s easily lost, and even though it’s selfish we value those moments of realization that we aren’t as dead inside as we pretend to be.

Which is to say: when the drowned kid died, my last day before I went on that huge long camping trip and didn’t post for a while, we were all devastated. His mother cried like an animal, gagging and groaning and clawing at her arms, and we all twisted our mouths and ground our teeth and remembered that we were people and wished we weren’t.

Rachel went home again. Her younger child’s birthday is coming up.

That same day, the last day before camping, I sent my open abd guy down to have his belly incision revised. They will slowly close it until at last his intestines are all contained, giving him time for the swelling to diminish between each revision. Then, because he wasn’t expected back up before my end of shift, I took two more pts: a comfort care pt in his thirties with Huntington’s, who was starting to lose his ability to swallow his secretions and was choosing to go home to die rather than move forward with a tracheostomy, and an older fellow with severe hearing loss who had come in for a very mild GI bleed from an ulcer in his stomach.

The comfort care pt’s case was relentlessly sad. His young wife is pregnant; he is not expected to live to see the child. He declined to make a video for the baby, saying that he didn’t want his son to see him like this. His family are rollicking good-ol-boy country folk, and they all sat in his room picking on him affectionately and watching Pawn Stars. They were delightful; they had faced this monster directly, and chosen not to be destroyed by its inevitable rampage, and as a result they were wonderfully supportive and caring. They helped move his cramped arms and roll him gently when he needed to be repositioned; they joked that his stubble “looked like wanderin’ pubes.” They ate five boxes of Fruit Roll-Ups in the room (making me crave Fruit Roll-Ups), and tirelessly suctioned his mouth with a soft plastic tube so he wouldn’t choke.

We tried out atropine drops to dry up his mouth, and they worked fairly well, although he still needed some suctioning from time to time. He was just waiting for the hospice group to pick him up in the morning and bring him home, where he can spend the rest of his life in comfort, surrounded by family. He got the shittest deal on the table, but I think he’s choosing the best possible option with it.

The GI bleed old guy told me about gladiator diets (beans and porridge, with burned plants to provide magnesium?) and house paint (never just use flat white, it looks too bare!) and nail storage (lots of yogurt containers!). He was advanced from a clear liquid diet to a full liquid diet, and delighted in his tray of four different kinds of soup instead of “all that sweet stuff they’ve been trying to trick me into eating.” He called me darlin’ and ma’am and Nurse Elise. He was an absolute doll and I wish all my pts were like him. Plan was to send him home the next day.

The next day I left for my camping trip, and haven’t been back to work yet. The trip was wonderful—I moved into a hammock by Lake Crescent, out on the peninsula, one of the prettiest places I’ve ever camped—and then I came home, finished my studying, took my CCRN exam, slept for a full day, and went to Cardiology Summer School today (first of three Fridays spread throughout the summer, lectures by a popular nurse educator in the area). Tomorrow, I go back to work.

I did stop by and check on my open abd guy. He is still alive and seems to be doing well, though the dialysis nurse was in his room setting up shop when I poked my head in. I didn’t see his abdomen, though. Maybe it’s closed by now. I will check his chart tomorrow and see what all has been going on while I was eating hot dogs and smores at the lake.

And I had my ninety-day review at this facility (I worked there for three months as a traveler before hiring on full time). My manager said there have been absolutely no complaints about me, which makes me pretty giddy, but added that the charge nurses were surprised by how easily I fell asleep on my nap breaks and how often I spend my breaks napping.

I really don’t know what to say to that. I’m fucking exhausted all the time at work and I sleep like a dead rock every chance I get. I just kind of stammered something about being ex-night-shift and wandered away. I thought break naps were one of the crucial characteristics of the nursing profession in general? Maybe I’m just lazy. That is a very real possibility.

I wonder if I’ll get my abd guy back tomorrow. I guess I should head to bed soon, since I have to be up in six hours. Shit, I think I figured out why I nap on all my breaks.