Every morning at my main facility we all cluster around the front station, receive our assignments, collect our walkie-talkies, and get a quick summary of the daily shift news. Yesterday’s morning started out very strangely for me, because I was unusually late and clocked in at 0645 exactly, when group report starts. This meant that by the time I made it to the front desk, everyone else already knew who I’d be taking care of, and they all watched me approach with this blend of pity and relief that told me right away what was about to happen.
I was getting an albatross.
I’ve only been working on this particular ICU for about six months, so I only have about three pts in my frequent-flyer nemesis roster. You get these pts by being unusually good at managing their bullshit, by being newer than everyone else and therefore not having been “fired” yet from the pt’s care team, or by having some other connection to them (speak their language, look like their beloved granddaughter, know how to pack their huge gross chronic wound) that makes it easier for you to take the assignment than for someone else. Everyone gets frequent fliers, and sometimes they become like mascots, or cute but frustrating pets, or (in rare cases) like part of the family.
Sometimes, though, they are mind-breaking time sinks with poor boundaries and unrealistic expectations of care and revolving-door care issues. They are chronically ill and rarely compliant. They have complicated needs that make it difficult to transfer or discharge them: mechanically ventilated at home, profoundly noncompliant with dialysis, covered in massive wounds, deathfat. Somehow they never fucking die.
Crowbarrens* is that guy. His metal-as-fuck name (I wish I could share the real thing) belies his whiny needy bitch-ass behavior and ready nurse-hitting fist. Bedbound at home with his neurodegenerative disease, he lives off his slavishly devoted wife, whom he bitches at and curses almost constantly, even when she’s not there. He hits; he demands female staff; he refuses to use a call bell and prefers to scream. His continual anxiety issues make him feel eternally short of breath, and his endless gargled litany of I CAN’T BREATHE, I CAN’T BREATHE doesn’t help much either. He uses his home ventilator with an uncuffed trach that allows him to eat, which he does every chance he gets, so he’s enormous. His tiny wife tries to placate him with food when he starts hitting her.
I don’t know why the hell they haven’t been broken up yet by some legal loophole. He returns to our ICU every three to four weeks like clockwork and is here for three to six days, minimum. This is because his wife gets frustrated and exhausted—he doesn’t let her sleep or leave the house, either—and calls 911 with some excuse, usually shortness of breath. Then she spends the few days of respite stocking the house, cleaning, sleeping, and getting ready to resume care for this complete turd of a human who will come back to her home and slap her around whenever she brings him anything he asks for.
Rumor has it, a few years back she snapped and took a baseball bat to him. Then she called 911 and reported that she had assaulted her husband, and meekly accompanied him to the hospital to await judgement; the social workers declined to get Adult Protective Services involved on grounds of “fucker had it coming.” I have no idea how true this is, but everyone believes it, which should tell you something about Crowbarrens.
What that means for his caregivers is constant verbal abuse, refused care, hitting, and bellowed orders. Nothing relieves his shortness of breath except heavy sedation. You can drug him into a stupor and he will still call out occasionally: I CAN’T BREATHE. We manage this with an endless parade of anxiolytics, opioids (to reduce respiratory drive), nebulized respiratory medications piped through his ventilator circuit, and verbal feedback on his oxygenation status (always 100%) and tidal volumes (always 850mL+). The distress is entirely perceived. Knowing this doesn’t help very much.
He’s my albatross because I am the tallest and meanest. (I’m not really the tallest anymore—I used to work on a unit where I was the only gangly white girl on a unit of tiny, shapely Filipina nurses and tiny, ancient Filipina senior nurses, so at 5’8” I was practically a human skyscraper. I come by the meanest part honestly though.) My whole family is insane and I am very accustomed to dealing with behaviorally difficult people, so when I get a Crowbarrens I kinda go for a three-part approach:
--First I try limit-setting and sharply defined boundaries. I will come into the room once every fifteen minutes; I will suction your trach once every hour. If I see anything alarming on the monitor or I have something to bring you, I will come more often than fifteen minutes, but you’ll see me or someone I send AT LEAST every fifteen minutes. I won’t suction your trach any more often because over-suctioning causes irritation, which will make you feel more short of breath. Every choice is presented not as ‘yes’ or ‘no’ but as ‘now’ or ‘later’.
--Failing that, I have the pt repeat the boundaries back to me, simplifying as necessary. When will I be coming back to the room? How do you call when you need me? Why are we going to wait a little longer on the trach suctioning? If their memory is too bad to handle a fifteen-minute break without forgetting, I start repeating a very rigid script instead of having them repeat back, validating concerns but not acting on them. Your oxygen level is 100% and you’re moving eight liters of air with each breath, which is very good. You must feel very short of breath, considering all the suctioning we’ve done lately, so I’m going to wait a little longer before I tickle your throat again.
--If that’s not successful, I have two options, depending on whether the pt is really too brain-fucked to comprehend anything or is just being a manipulative ass. In the former case, I go completely apeshit and spend the whole shift wishing I could die and/or binge on Netflix instead of being at work. In the latter case, I assume there’s some personality disorder on the same spectrum with borderline, and foster a desperate sense of dependency and attachment. This is not at all healthy, I’m sure, but there you have it: Crowbarrens and his wife haven’t fired me yet, and even though I am the number-one asshole on the unit and force him to do awful things like ‘sit in a chair’ and ‘take pills’ and ‘fear my disapproval so much that he keeps his hands to himself’, he still asks for me by name.
Lucky me.
So that was my day. Somebody had loaded him with bowel medications and he was shitting like Mt. St. Helens every forty-five minutes. Most of the boundaries and limits from the last visit held nicely, though, and as long as I held up my end of the bargain—every fifteen minutes, without fail—he behaved himself and even calmed down when I told him his breathing was fine.
HD lady was, some fucking how, still alive. She even woke up enough to start refusing dialysis and telling her kids she's ready to die. Yeah, they took her down for another washout, patched her gut, and now we're just waiting for the next hose to pop.
I could NOT believe she was still alive. Not only should that last leak have killed her, but anybody with decision-making power should have seen the amount of Saw-level torture we're putting her through and called a halt. God save us all from the mercy of our grandchildren.
My other pt was a cute old guy who had gone into flash pulmonary edema a couple days after having a lobe of his lung removed because of a lump. He was intubated and sedated and his family was sweet and anxious. Lots of education about his condition, pathophysiology, and medical needs. The intensivist did a speed-bronchoscopy at his bedside, sucked out a few mucus plugs, and declared him “probably ready to extubate tomorrow.” He was sicker than Crowbarrens, but much much less work.
After the 1500 shift change I finally got my lunch break, and spent it unconscious. From outside the break room, as I drifted off, I could hear Crowbarrens yelling. Fuck you, old guy. Take a fifteen-minute break from swinging at people, okay?
At 1530, as I emerged blinking and drool-crusted from the break room with pillow-lines on my face, my HD lady was extubated to comfort-only care. Her family had finally read the writing on the wall, and agreed to let her go.
She woke up a little after they extubated her, and was able to say a few words to her husband before she passed: "Love you, ???? bear. Love you sweetie."
I didn't catch all of it. Her whole family gathered in the room, grieving. She was loved.
Later I got the hell into it with one of the CNAs. She is very experienced and has worked on that unit for a long time, and is in nursing school, but this seems to manifest in her as a) she knows fucking everything and tries to tell you what to do and b) she is almost impossible to pin down for turns and clean-ups and other mundane chores. There is a standing rule that if a CNA comes to help a nurse and the nurse isn’t ready to do the job, the CNA moves on to the next chore and comes back whenever.
To this CNA, that means if I call her up and ask her to grab a bottom sheet while I grab the wipes and then meet me in room 20 to clean up a poopslide, my lack of sheet & wipes means I’m “not ready” and she’s not obliged to help me. Plus, if I call her and she’s busy but “will be there in a bit,” that means she’ll sweep by in anywhere from five to thirty minutes and if I’m not standing at the bedside with the whole room ready to go, instead of calling me back, she just moves on. She also bails on any cleanup or chore the moment the absolute essentials are done, leaving me with a trash can full of shit, a half-naked patient whose crotch I’m still wiping, and a pile of unshod pillows that will need cases put on before I can use them to prop up the pt’s arms and legs.
The critical parts, to her, are the parts where we take turns lifting the pt to wipe ass and roll the laundry out of the way, then put clean laundry and two pillows under their butt. The rest is for me to do. She’s busy, you see.
So as the intensivist set up next door for his speed-bronch, calling me repeatedly so he could get his job done, I was still up to my elbows in Crowbarrens’s panniculus, trying to get him clean enough and decent enough to leave him alone for thirty minutes, breathing the incredible stink of the trash can full of shit that the fucking CNA had actively declined to carry across the hall and throw away on her way out. What would have taken two people maybe five minutes to finish up took me fifteen, during which time the intensivist cooled his heels. I didn’t get the room finished until after the bronch, which meant the room was filthy and reeking when the pt’s wife showed up to visit.
CNA work is incredibly exhausting and difficult. It’s easy to burn out. It can be tricky to negotiate when you have different ideas about what you’re supposed to do. I have met very few CNAs I didn’t respect enormously. But her bare-minimum practice makes my job incredibly hard sometimes, and I definitely caught her in the hallway later and Had Words. She expressed that I was a crazy and demanding asshole and that my expectation that she would grab laundry on the way to bed changes and help finish cleanups was completely unrealistic. I said I would arrange to have everything at the bedside when I called her, but that I expected her to follow up with me if I wasn’t in the room more than ten minutes after my first call, and that I expected her to stick with cleanups until the room was either moderately decent for family to see, or until the nurse specifically said she wasn’t needed anymore.
This is the extent of my conflict management skills. She tentatively agreed but also said she expected me to “behave myself.” Not sure what that means exactly.
It set a bad tone for the end of my shift. I walked back into Crowbarrens’s room, caught him berating his wife, and chewed him out until he actually apologized. I must have looked like some kind of glass-eyed monster. Then I sat outside the room, making stern eye contact with him the whole time until my relief came on. He did not once complain of shortness of breath. I think he finally found something else to worry about.
Then I went home, opened my laptop, and fell asleep before I could even log into facebook. So that was my shift.
Showing posts with label CRRT. Show all posts
Showing posts with label CRRT. Show all posts
Tuesday, July 14, 2015
Sunday, July 12, 2015
Week 2 Shift 1
By the time I clocked in yesterday morning, the fem-pop guy had been transferred to a telemetry unit in preparation to have him go home later in the day, the neurodegenerative guy had been sent home on hospice (probably won't die immediately, but will be allowed to drink water instead of begging for swabs), and the intensivist was standing at the front station talking about Rachel*, the birthday mom, and her swallow study later that day. They planned to try her out on a Passy-Muir valve, a type of tracheostomy apparatus that allows the pt to push a button so that they can speak and eat.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
Saturday, July 11, 2015
Week 1 Shift 3 (7 of 7)
I slept until 0900 this morning, laid in bed playing Monument Valley on my phone until 1045 (I have legitimately not played this game at all despite all my friends telling me I would love it), then convinced myself that brunch and a shower sounded better than just lying in bed forever. The shower was amazing because it took place in the middle of the day with no time constraints and I could shave everything and spend plenty of time staring at the wall and thinking about absolutely nothing. Showers are usually ten minutes of scrubbing, shampooing, and telling myself aloud: "Come on, come on, you're okay." They usually take place at 0530.
This shower went on so long that I made my husband bring me hot tea with milk and sugar, which I drank in the shower, setting it on the little shelf between sips. He stuck around and sat on the (closed, hopefully) toilet and told me about the airplanes he saw at the flight museum restoration hangar last week. We haven't seen much of each other this week, so while I care very little about airplanes, it's nice to hear him talk about things he likes.
Then I had a fucking decadent brunch before time for him to head to school. Now I am sitting in a nest of blankets and pillows on the sofa. The coffee table is arranged with the accoutrements of another couple of dumb hobbies of mine, different types of tea in several french presses and teapots + an honest to god thirteen jars of different kinds of honey. I had a weekend in Hawaii recently and bought YET ANOTHER sampler set of honey and I like to sit with my tea and my honey and a pile of chopsticks and compare the different flavors. If I had a shit-ton of different kinds of cheese this setup would be perfect. Hi, yes, I am the most boring person you have ever met.
The point of all this is: I will write up this report in extreme comfort.
Yesterday morning I took report on my CRRT pt, whose renal replacement therapy had been turned off overnight in preparation for the day's dialysis, and another pt who was preparing for discharge after having a cardiac stent placed. I made sure the first pt was comfortable and all her drips were stable-- she was still requiring a little bit of norepinephrine to keep her blood pressure up-- and then settled in to discharge the stent guy in record time. (Different stent guy from the previous shift. That dude was still checked in down the hallway, ringing his call bell constantly to ask if random tiny things meant he was dying. I answered a few of those calls while his nurse was busy, and reassured him that a random itch on his foot, a mild headache, and a restless feeling in his legs were not in fact signs of imminent death, though I was a bit more tactful about it.)
Taught the stent guy about his new blood-thinning medications and blood-pressure medications. He had a lazy eye that wandered around as I talked to him. Very difficult not to attempt normal eye-contact interactions with the lazy eye. Very polite and personable fellow, I just have a weird thing about lazy eyes that I have to compensate for so as to keep from being an asshole. Finished the discharge, pulled out his IV, and called the transporter to come wheel him down to his wife's car.
Caught up on my lady next door, whose blood pressure was kind of labile. Part of it was that I'd been measuring her BP mostly by an arterial line, which is a notoriously finicky process. I suspected she was also having breakthrough pain even under sedation. Turned up her fentanyl and crossed my fingers that I wouldn't bomb her pressure, and voila, she evened out. I don't blame her. The semi-open abdomen thing looks like hell. Her colon rind drainage was significantly reduced in volume and more liquid today. Her toes still look like shit-- she had very high doses of norepinephrine (also known as levophed) to keep her alive during the height of her illness, and norepi is well known for constricting your blood vessels until your toes turn black and drop off. Pt's family kept massaging the gross purple-black toes, trying to bring back circulation. Educated them on the importance of not dumping dead-tissue toxins into the bloodstream. Yes, she will probably lose most of her toes, although she stands a decent chance of living, so stop trying to milk rotten toe-meat back into her arteries, we cool?
Her toenails were solid lumps of fungus. Family was bare-handing that shit. I must just be squeamish from hospital work but I wanted to throw up just watching it.
Got caught up, oh my god, and went to help out down the hallway, where another nurse was landing a complete clusterfuck of a situation from the operating room. Her pt was an attractive lady in her fifties, wearing the kind of makeup you see on real estate agents, bleeding like a Tarantino extra from all her holes with her gut laid wide open under a delicate sheeting of saline-soaked gauze. Apparently she had been at work earlier and felt something 'pop'. Perforated small bowel, plus during surgery the MD had discovered a previously stable renal-aortic aneurysm which began to dissect under the stress. Deeply sedated and intubated, of course, but the room was a disaster area and the nurse was frantic. I called lab for her to make sure they'd started processing the pt's stat hematocrit, which they had not because uh, oops, then drew more labs, read blood, and generally did scut work for about half an hour until things started to calm down.
One 'reads' blood by verifying all its information against the pt's armband, the computer's cross-checking sheet, and the various stickers on the bag of blood itself. Giving a pt the wrong blood can be swiftly and horribly fatal. Two RNs are always required for blood checks.
Bailed out of that room to attend rounds for my lady. Rounds involves an assortment of hospital professionals, the care team, who circulate through the ICU in the morning and check up on all the pts to make sure nothing is missed. The intensivist, pharmacist, nutritionist, charge nurse, physical therapist charge, respiratory technician charge, and occasionally others like the infection control specialist or the social worker all gather up with their rolling computer carts and surround you, and you give report and talk about any concerns or plans for the day.
Code blue by the front nurses station, yesterday's first heart-surgery pt. The pt's daughter came screaming and jumping out into the hallway, having pressed the code button herself. She was apparently an RN herself. The code team swarmed in and found that he wasn't dead dead, he was just having a massive vagal response from bearing down hard on the shitter while his heart was still stiff and shocky after surgery. Sigh of relief all around-- he wasn't an open-heart valve repair, just a triple bypass, so he didn't have pacer wires still installed (we keep them in the valve pts for a long time because valve surgery often disrupts the nerve pathway through the heart, resulting in sudden drop-dead moments like that one guy the other day) and therefore wouldn't have been an easy fix (seriously, nothing is easier than bringing back a valve pt with a pacemaker).
The housekeeper came by to stat clean the now-empty room where the stent guy was before. Why a stat clean, I asked her? Oh, she said, you're getting a patient in this room. Me specifically? That's what the charge nurse said. WHAT THE FUCK. I call the charge nurse and ask if this is true, and sure enough, I am getting a femoral-popliteal bypass case from the OR in about thirty minutes. Oh, I didn't tell you? I'm sorry.
The lack of communication is killing me. Toward the beginning of this run of days I was caring for three telemetry-level pts (a step down from ICU critical care), preparing one for a routine cardioversion, which for tele pts involves the team carrying them down to Special Procedures and bringing them back when they're finished. Instead, the whole team showed up at the bedside and asked me where the paralytics were. Turns out, somebody had decided to intubate the pt, perform a trans-esophageal echocardiogram (heart ultrasound from inside the esophagus), and cardiovert (shock the heart to break the pt out of a dangerously fast rhythm) AT THE BEDSIDE. Assurances that the pt would be made critical-care status. I ended up demanding that the flex RN take over that pt one-to-one, and I'm glad I did, because she turned out to be an utter disaster and there was nobody to take my other two teles.
And after the previous shift's CRRT ambush, I really was not feeling good about the communication level with that charge nurse.
Turns out though that she was just trying to make sure I got the easier of the two incoming pts, and had been delayed in telling me because the RN getting the other pt needed a lot of help setting up. Not excused, but understandable.
Elevator call: my pt was on his way up. Out of nowhere, code blue. A pt on the other end of the unit who had been on a balloon pump-- a sausage-shaped balloon in his aorta that helped pump blood with each heartbeat, really cool tech but very risky-- had gone into cardiac arrest. The whole unit poured into that room to bring the guy back to life, leaving me to admit the new guy alone. This sounds worse than it is, mainly because the new guy was super nice and his wife was super nice and everything had gone without a hiccup. His potassium was very high, because his kidneys were chronically insufficient and he couldn't shed potassium very well, so I gave him a medicine to drink that gives you insane diarrhea but dumps all your potassium through your butthole. He was not happy about this, but he understood. We looked up all of his meds together and made sure everything else was right.
He kept asking to pee, but he had a foley catheter in-- a tube that goes up your dick into your bladder to drain it. I kept telling him to pee whenever he needed to, but honestly, foleys are uncomfortable as shit. His leg looked great where the closed-off arteries had been bypassed and his pulses were strong. The incisions were minimal. I told him he'd be bikini-ready in six weeks and he laughed and spilled his cranberry juice everywhere.
The balloon pump pt survived, but was for some reason immediately moved into full airborne precautions, the kind we use for tuberculosis. I still have no idea what that was about, but the nurses involved in that disaster were totally isolated for the rest of the shift, wearing bubble helmet respirators and gowns in an airlocked room at the end of the unit. I can't even imagine taking care of a fucking balloon pump pt while under full airborne precautions. I am a sucker for high-acuity pts but that just sounds exhausting.
Dialysis nurse showed up in the next room. I love it when my pts go on dialysis because they get a dedicated nurse to run the machine, which means I don't have to watch as closely because somebody with at least half a brain will let me know if anything's changing. Sure enough, as soon as he hooked her up, her blood pressure on the arterial line dumped. We both panicked a little and tried a few things, but nothing was touching that shitty blood pressure. I noted that the dialysis catheter was accessed on the same side as the brachial art line, suspected that the arterial outflow through the HD cath was sucking pressure away from the art line, and put a BP cuff on her other arm. Sure enough, her BP was fine. Maybe a little on the high side. Fuck yes, dialysis go.
Helped a nurse the next room over with bathing and prettying up her pt. I have taken care of this pt frequently over the month she's been on our ICU. She's in her thirties, a mother of two and part-time special-needs tutor, with a sweet-faced husband at her bedside constantly. She was very healthy before this, got strep pneumonia that turned into necrotizing pneumonia, had half her right lung cut out, held a fever of 38.9C+ for two weeks, coded twice, nearly died more times than I care to count, swelled up into a water balloon, lost all the water and is now sunken and sallow, now has a tracheostomy and a chest tube, and has generally been so much work to keep alive that we rotate on and off so nobody gets completely worn out on her. She's been better this week, though. Her husband didn't want to bring her kids in while she was super sick, for obvious reasons, and they're like two and five anyway so it's not entirely safe to have them on the ICU.
This was her older child's sixth birthday, so we arranged a surprise for her. Her husband went home "for the afternoon" like usual, to pick up the kids, and her nurse and I washed her hair and generally made her presentable and even pretty while the charge nurse ordered cupcakes from a nearby bakery (with extras for staff because fuck yeah, petty cash). We sat her up in the chair and she was watching a little TV when her husband returned with a pile of presents, a slice of birthday cake, and her now-six-year-old son wearing a paper crown. He started screaming as soon as we let him in the room, and she cried and managed to hold her arms up long enough to hug him. The whole fucking unit's worth of staff was gathered around that room, let me tell you.
The kid showed her his new spiderman doll and his books, opened a couple of presents and discovered a spiderman backpack and a candy bar, jumped around the room with delight, and could NOT stop telling his mother everything that had happened that week at school. After a while her crying started to really confuse him, and he asked: "Why are you sad?" Climbed into her lap (nurse at hand to keep the chest tube from getting kicked) and started fucking wiping the tears off her face. Then he started crying too, wiped his own face, and announced in bafflement: "I'm not sad!"
Look, we don't get a lot of great stories like this on the ICU. Most people die, or have long slow shitty recoveries, or are 107 and should have died anyway, or are just here for a quick cardiac stent and go home the next day without realizing they totally clipped Death's elbow in the cath lab elevator. We are all cynical assholes who don't get our hopes up. Most of us hate children. This shit made every last one of us cry like morons. Fuck. Moving on.
She's supposed to go to rehab next week after the chest tube comes out. Prognosis is pretty good at this point.
Back to the lady on dialysis. I did her dressing change, packing saline-soaked gauze into the open places on her belly and covering it with dry dressings. The colon-rind liquid coming out of her drain was starting to clear up a bit, and had the texture of hot sauce rather than ketchup. Her left arm, where the blood pressure cuff was squeezing her forearm below her PICC line, was incredibly swollen, like the whole thing from fingertips to shoulder. Oh god, she's totally getting a DVT.
PICC lines, because they're long IV lines that follow an entire vein back to the heart, are prone to gathering clots around them. A big clot in a large deep vein-- a Deep Vein Thrombosis-- can be a major issue. I took off the cuff and helped the dialysis nurse lock and pack her dialysis catheter-- she was done with the run and had tolerated it well-- and prepared the room for report to the next nurse. I realized I couldn't remember whether the opthamologist came by today; she was supposed to get her eyes checked to make sure that her fixed upward stare isn't a sign of nerve damage, like a yeast-clot stroke behind the eyes. All in all, though, I felt pretty good about the day; my fem-pop guy was having great pain control and excellent pulses and a nap after dinner, my HD lady was down 3.5 liters of fluid and a bunch of toxins and will start losing some of her swelling soon (hopefully), the lady next door was wrapping up the world's most tearjerky birthday party, and the open-gut lady down the hall was starting to pull out of her tailspin.
I left the hospital about thirty minutes late, had home-cooked dinner with my friends and their disastrously cute 2.5yo kid, listened to podcasts about birdcalls because one of them is really into podcasts (fuckin nerd lol), and don't really remember how I got home.
This shower went on so long that I made my husband bring me hot tea with milk and sugar, which I drank in the shower, setting it on the little shelf between sips. He stuck around and sat on the (closed, hopefully) toilet and told me about the airplanes he saw at the flight museum restoration hangar last week. We haven't seen much of each other this week, so while I care very little about airplanes, it's nice to hear him talk about things he likes.
Then I had a fucking decadent brunch before time for him to head to school. Now I am sitting in a nest of blankets and pillows on the sofa. The coffee table is arranged with the accoutrements of another couple of dumb hobbies of mine, different types of tea in several french presses and teapots + an honest to god thirteen jars of different kinds of honey. I had a weekend in Hawaii recently and bought YET ANOTHER sampler set of honey and I like to sit with my tea and my honey and a pile of chopsticks and compare the different flavors. If I had a shit-ton of different kinds of cheese this setup would be perfect. Hi, yes, I am the most boring person you have ever met.
The point of all this is: I will write up this report in extreme comfort.
Yesterday morning I took report on my CRRT pt, whose renal replacement therapy had been turned off overnight in preparation for the day's dialysis, and another pt who was preparing for discharge after having a cardiac stent placed. I made sure the first pt was comfortable and all her drips were stable-- she was still requiring a little bit of norepinephrine to keep her blood pressure up-- and then settled in to discharge the stent guy in record time. (Different stent guy from the previous shift. That dude was still checked in down the hallway, ringing his call bell constantly to ask if random tiny things meant he was dying. I answered a few of those calls while his nurse was busy, and reassured him that a random itch on his foot, a mild headache, and a restless feeling in his legs were not in fact signs of imminent death, though I was a bit more tactful about it.)
Taught the stent guy about his new blood-thinning medications and blood-pressure medications. He had a lazy eye that wandered around as I talked to him. Very difficult not to attempt normal eye-contact interactions with the lazy eye. Very polite and personable fellow, I just have a weird thing about lazy eyes that I have to compensate for so as to keep from being an asshole. Finished the discharge, pulled out his IV, and called the transporter to come wheel him down to his wife's car.
Caught up on my lady next door, whose blood pressure was kind of labile. Part of it was that I'd been measuring her BP mostly by an arterial line, which is a notoriously finicky process. I suspected she was also having breakthrough pain even under sedation. Turned up her fentanyl and crossed my fingers that I wouldn't bomb her pressure, and voila, she evened out. I don't blame her. The semi-open abdomen thing looks like hell. Her colon rind drainage was significantly reduced in volume and more liquid today. Her toes still look like shit-- she had very high doses of norepinephrine (also known as levophed) to keep her alive during the height of her illness, and norepi is well known for constricting your blood vessels until your toes turn black and drop off. Pt's family kept massaging the gross purple-black toes, trying to bring back circulation. Educated them on the importance of not dumping dead-tissue toxins into the bloodstream. Yes, she will probably lose most of her toes, although she stands a decent chance of living, so stop trying to milk rotten toe-meat back into her arteries, we cool?
Her toenails were solid lumps of fungus. Family was bare-handing that shit. I must just be squeamish from hospital work but I wanted to throw up just watching it.
Got caught up, oh my god, and went to help out down the hallway, where another nurse was landing a complete clusterfuck of a situation from the operating room. Her pt was an attractive lady in her fifties, wearing the kind of makeup you see on real estate agents, bleeding like a Tarantino extra from all her holes with her gut laid wide open under a delicate sheeting of saline-soaked gauze. Apparently she had been at work earlier and felt something 'pop'. Perforated small bowel, plus during surgery the MD had discovered a previously stable renal-aortic aneurysm which began to dissect under the stress. Deeply sedated and intubated, of course, but the room was a disaster area and the nurse was frantic. I called lab for her to make sure they'd started processing the pt's stat hematocrit, which they had not because uh, oops, then drew more labs, read blood, and generally did scut work for about half an hour until things started to calm down.
One 'reads' blood by verifying all its information against the pt's armband, the computer's cross-checking sheet, and the various stickers on the bag of blood itself. Giving a pt the wrong blood can be swiftly and horribly fatal. Two RNs are always required for blood checks.
Bailed out of that room to attend rounds for my lady. Rounds involves an assortment of hospital professionals, the care team, who circulate through the ICU in the morning and check up on all the pts to make sure nothing is missed. The intensivist, pharmacist, nutritionist, charge nurse, physical therapist charge, respiratory technician charge, and occasionally others like the infection control specialist or the social worker all gather up with their rolling computer carts and surround you, and you give report and talk about any concerns or plans for the day.
Code blue by the front nurses station, yesterday's first heart-surgery pt. The pt's daughter came screaming and jumping out into the hallway, having pressed the code button herself. She was apparently an RN herself. The code team swarmed in and found that he wasn't dead dead, he was just having a massive vagal response from bearing down hard on the shitter while his heart was still stiff and shocky after surgery. Sigh of relief all around-- he wasn't an open-heart valve repair, just a triple bypass, so he didn't have pacer wires still installed (we keep them in the valve pts for a long time because valve surgery often disrupts the nerve pathway through the heart, resulting in sudden drop-dead moments like that one guy the other day) and therefore wouldn't have been an easy fix (seriously, nothing is easier than bringing back a valve pt with a pacemaker).
The housekeeper came by to stat clean the now-empty room where the stent guy was before. Why a stat clean, I asked her? Oh, she said, you're getting a patient in this room. Me specifically? That's what the charge nurse said. WHAT THE FUCK. I call the charge nurse and ask if this is true, and sure enough, I am getting a femoral-popliteal bypass case from the OR in about thirty minutes. Oh, I didn't tell you? I'm sorry.
The lack of communication is killing me. Toward the beginning of this run of days I was caring for three telemetry-level pts (a step down from ICU critical care), preparing one for a routine cardioversion, which for tele pts involves the team carrying them down to Special Procedures and bringing them back when they're finished. Instead, the whole team showed up at the bedside and asked me where the paralytics were. Turns out, somebody had decided to intubate the pt, perform a trans-esophageal echocardiogram (heart ultrasound from inside the esophagus), and cardiovert (shock the heart to break the pt out of a dangerously fast rhythm) AT THE BEDSIDE. Assurances that the pt would be made critical-care status. I ended up demanding that the flex RN take over that pt one-to-one, and I'm glad I did, because she turned out to be an utter disaster and there was nobody to take my other two teles.
And after the previous shift's CRRT ambush, I really was not feeling good about the communication level with that charge nurse.
Turns out though that she was just trying to make sure I got the easier of the two incoming pts, and had been delayed in telling me because the RN getting the other pt needed a lot of help setting up. Not excused, but understandable.
Elevator call: my pt was on his way up. Out of nowhere, code blue. A pt on the other end of the unit who had been on a balloon pump-- a sausage-shaped balloon in his aorta that helped pump blood with each heartbeat, really cool tech but very risky-- had gone into cardiac arrest. The whole unit poured into that room to bring the guy back to life, leaving me to admit the new guy alone. This sounds worse than it is, mainly because the new guy was super nice and his wife was super nice and everything had gone without a hiccup. His potassium was very high, because his kidneys were chronically insufficient and he couldn't shed potassium very well, so I gave him a medicine to drink that gives you insane diarrhea but dumps all your potassium through your butthole. He was not happy about this, but he understood. We looked up all of his meds together and made sure everything else was right.
He kept asking to pee, but he had a foley catheter in-- a tube that goes up your dick into your bladder to drain it. I kept telling him to pee whenever he needed to, but honestly, foleys are uncomfortable as shit. His leg looked great where the closed-off arteries had been bypassed and his pulses were strong. The incisions were minimal. I told him he'd be bikini-ready in six weeks and he laughed and spilled his cranberry juice everywhere.
The balloon pump pt survived, but was for some reason immediately moved into full airborne precautions, the kind we use for tuberculosis. I still have no idea what that was about, but the nurses involved in that disaster were totally isolated for the rest of the shift, wearing bubble helmet respirators and gowns in an airlocked room at the end of the unit. I can't even imagine taking care of a fucking balloon pump pt while under full airborne precautions. I am a sucker for high-acuity pts but that just sounds exhausting.
Dialysis nurse showed up in the next room. I love it when my pts go on dialysis because they get a dedicated nurse to run the machine, which means I don't have to watch as closely because somebody with at least half a brain will let me know if anything's changing. Sure enough, as soon as he hooked her up, her blood pressure on the arterial line dumped. We both panicked a little and tried a few things, but nothing was touching that shitty blood pressure. I noted that the dialysis catheter was accessed on the same side as the brachial art line, suspected that the arterial outflow through the HD cath was sucking pressure away from the art line, and put a BP cuff on her other arm. Sure enough, her BP was fine. Maybe a little on the high side. Fuck yes, dialysis go.
Helped a nurse the next room over with bathing and prettying up her pt. I have taken care of this pt frequently over the month she's been on our ICU. She's in her thirties, a mother of two and part-time special-needs tutor, with a sweet-faced husband at her bedside constantly. She was very healthy before this, got strep pneumonia that turned into necrotizing pneumonia, had half her right lung cut out, held a fever of 38.9C+ for two weeks, coded twice, nearly died more times than I care to count, swelled up into a water balloon, lost all the water and is now sunken and sallow, now has a tracheostomy and a chest tube, and has generally been so much work to keep alive that we rotate on and off so nobody gets completely worn out on her. She's been better this week, though. Her husband didn't want to bring her kids in while she was super sick, for obvious reasons, and they're like two and five anyway so it's not entirely safe to have them on the ICU.
This was her older child's sixth birthday, so we arranged a surprise for her. Her husband went home "for the afternoon" like usual, to pick up the kids, and her nurse and I washed her hair and generally made her presentable and even pretty while the charge nurse ordered cupcakes from a nearby bakery (with extras for staff because fuck yeah, petty cash). We sat her up in the chair and she was watching a little TV when her husband returned with a pile of presents, a slice of birthday cake, and her now-six-year-old son wearing a paper crown. He started screaming as soon as we let him in the room, and she cried and managed to hold her arms up long enough to hug him. The whole fucking unit's worth of staff was gathered around that room, let me tell you.
The kid showed her his new spiderman doll and his books, opened a couple of presents and discovered a spiderman backpack and a candy bar, jumped around the room with delight, and could NOT stop telling his mother everything that had happened that week at school. After a while her crying started to really confuse him, and he asked: "Why are you sad?" Climbed into her lap (nurse at hand to keep the chest tube from getting kicked) and started fucking wiping the tears off her face. Then he started crying too, wiped his own face, and announced in bafflement: "I'm not sad!"
Look, we don't get a lot of great stories like this on the ICU. Most people die, or have long slow shitty recoveries, or are 107 and should have died anyway, or are just here for a quick cardiac stent and go home the next day without realizing they totally clipped Death's elbow in the cath lab elevator. We are all cynical assholes who don't get our hopes up. Most of us hate children. This shit made every last one of us cry like morons. Fuck. Moving on.
She's supposed to go to rehab next week after the chest tube comes out. Prognosis is pretty good at this point.
Back to the lady on dialysis. I did her dressing change, packing saline-soaked gauze into the open places on her belly and covering it with dry dressings. The colon-rind liquid coming out of her drain was starting to clear up a bit, and had the texture of hot sauce rather than ketchup. Her left arm, where the blood pressure cuff was squeezing her forearm below her PICC line, was incredibly swollen, like the whole thing from fingertips to shoulder. Oh god, she's totally getting a DVT.
PICC lines, because they're long IV lines that follow an entire vein back to the heart, are prone to gathering clots around them. A big clot in a large deep vein-- a Deep Vein Thrombosis-- can be a major issue. I took off the cuff and helped the dialysis nurse lock and pack her dialysis catheter-- she was done with the run and had tolerated it well-- and prepared the room for report to the next nurse. I realized I couldn't remember whether the opthamologist came by today; she was supposed to get her eyes checked to make sure that her fixed upward stare isn't a sign of nerve damage, like a yeast-clot stroke behind the eyes. All in all, though, I felt pretty good about the day; my fem-pop guy was having great pain control and excellent pulses and a nap after dinner, my HD lady was down 3.5 liters of fluid and a bunch of toxins and will start losing some of her swelling soon (hopefully), the lady next door was wrapping up the world's most tearjerky birthday party, and the open-gut lady down the hall was starting to pull out of her tailspin.
I left the hospital about thirty minutes late, had home-cooked dinner with my friends and their disastrously cute 2.5yo kid, listened to podcasts about birdcalls because one of them is really into podcasts (fuckin nerd lol), and don't really remember how I got home.
Friday, July 10, 2015
Week 1 Shift 2 (technically 6 of 7)
Today started off much better than yesterday. Got my pts back; the little old man with bradycardia recovered overnight and was able to go home by 0930 without having to get a pacemaker. He was delighted and I was also glad for him, not least because getting discharged to home from the ICU almost never happens before lunch. I am a discharge beast though. Spent maybe twenty minutes after his discharge quietly charting in the end of the hallway where the lights hadn't been turned up yet. The suction canister in the empty room created a strange auditory illusion, as if I were sitting near a pond full of frogs all chiming at once. The dim light and weirdly outdoor sound is very soothing and I am relaxed as I drink my first coffee of the day and finish documenting that my patients are still alive and functioning.
The neurodegenerative guy was amazingly improved by the administration of pain meds overnight. Even his swallow was stronger (or else, quite possibly, he's so fucked up that he can't tell when water slides into his lungs and doesn't bother coughing), so tomorrow he's gonna get a barium swallow study-- swallowing barium-enriched fluids in front of an X-ray-- and if he passes that he can eat again. Crossing my fingers for you, dude.
Also got a PICC line in him, which is a long IV that goes all the way up your arm into your heart, allowing us to give you much stronger and more concentrated medications without injuring or burning your veins-- things like potassium, which is very painful given through a peripheral IV, and total parenteral nutrition aka IV food. Palliative Care came by and talked to his brother about his end-of-life wishes and the possibility of transferring him back to his adult family home on hospice, where he can live out the rest of his days with his treatment focus being comfort rather than recovery. Physical Therapy has a hard time working with him because he has so much pain.
He apologizes every time he asks for anything, or anything is offered to him. He is pathetically grateful and wary in a way that reminds me of an abused dog, and I asked the social worker if anything needed looking into. We agreed to defer any investigation until the psych team came by to see him, since he'd had no psych meds for days and is technically schizophrenic. Sure enough, he was having a massive onslaught of hateful and abusive voices telling him that he was a bad patient and deserved to die and that the people here were waiting for him to go to sleep so they could hurt him. Jesus motherfucker. We started him on orally-dissolving cheek-absorbed olanzapine to help him. It's really easy for things to slip through the cracks, but I could kick myself for not pushing sooner for other psych med vectors.
Meanwhile, I replaced my old bradycardia dude with a new guy from the cath lab, a fifty-year-old man with a history of morbid obesity, prior V-fib arrest, two cardiac stents, heart failure, diuretics and sodium restriction, diabetes, chronic renal insufficiency, and a pacemaker. He and his whole family reeked of cigarette smoke and not one of them weighed less than a Ford pickup. "Genetics," he said. "My bad luck. Dad had a bad heart too." I mean, no. It's not genetics. You might be a nice dude, but you're also fat as hell and it's literally killing you. Your blood is so sugary it's shredding your heart from inside out and your blood fats are so high that butter chunks the size of thimbles are bobbing in your aorta, and THAT, my friend, is why you're dying.
He had another stent placed, a 98% OM occlusion roto-rootered out. Lingering reperfusion pain. Nitroglycerin, morphine, and a nice neighborly dose of ativan fixed him right up. Still had the arterial sheath in his groin where they'd gone in, done up nice and neat with a syringe of heparin taped to it and the line clamped, presumably full of anticoagulant. Orders to remove it two hours after the last bit of anti-clotting agent went in. He complained nonstop about having to keep his leg straight, which I understand sucks, but also which I understand is LESS horrible than 10/10 crushing chest pain with blue-lipped shortness of breath. Maybe my priorities are fucked.
After that it was just putting out fires for a while, but sooo many fires. The next pt down the hall was receiving continuous renal replacement therapy, a sort of constant bedside low-grade dialysis that requires a one-to-one nurse who can constantly monitor and adjust it. Nobody else on the floor besides that nurse was checked off to handle CRRT, but I've done it at other facilities a million times, so the charge nurse asked if I could break the CRRT nurse for lunch. No big, done. Then gave another nurse a break-- I've had both of her pts before and knew them well enough to need very little report.
Stent guy wanted lunch, but declared that he hated hospital food. Family offered to go get him something to eat. "I want one of those bacon crab mac and cheese plates from Cheesecake Factory and an order of crispy egg rolls," he said.
"I'm so sorry," I cut in, "but both of those are definitely off the menu. Let's see if we can come up with something better for you."
"Why can't I eat what I want? I'm sick, I need comfort food."
"Sir, you just had a heart attack."
He looked at me like I had just started speaking Urdu. "...And?"
Family left with orders not to bring him ANYTHING and a very pointed hint that they might want to attend his meeting with the nutritionist tomorrow.
Pt ordered a burger from the hospital menu for dinner. Did not want light mayonnaise. Angry that the burger would not include cheese. Asked if he could have three burgers, hold all the veggies. Dietary declined and pointed out that this would put him far over his daily salt intake limit. Pt stewed for an hour, then called his mother and asked her to sneak him a cheesecake.
Darwin is coming for you, sir.
At this point, exhausted, I went into neuro guy's room to give him a tylenol (paracetamol) suppository, his IV antibiotic, and his IV metoprolol. The cheek-dissolving schizophrenia med was nowhere to be found; I messaged pharmacy to have it sent up. Everything was due at 1400, an hour before shift change for the eight-hour nurses (not me) at 1500, so there was a line for the drug machine. He was pooping in his bed, and his previous IV medication wasn't done yet, so I figured I would go take a lunch nap for thirty minutes and come back at 1445 to finish everything.
At 1440 the charge nurse woke me up and told me I would be taking the CRRT pt at 1500, checked off or no, because that nurse had to go home and there wasn't anyone else to cover. Fuuuuuuuuck. I went and gave report to the oncoming nurse, apologizing for the state of things, putting the cheek-dissolving medication from the tube station straight into her hand, and helping her clean and turn the guy (who had finished pooping). Then I dashed over and took the world's most intense report on the CRRT pt, who was preparing to have her CRRT run ended so that tomorrow she could have normal dialysis. CRRT is mostly the same wherever you go, but the charting varies a bit.
Oncoming nurse for my other pts comes into the room, raging. She is very upset that I left her so many chores to do. The room was messy, the meds weren't given on time, the orders weren't cleaned up, etc etc. I stare at her in bewilderment. Did I not tell her explicitly that I got ambushed with a pt exchange? I walked her through all of this, I know I did. I helped her clean up the guy. What is happening.
Oh. That sheath I was going to pull at 1500, the one that was heparin-filled to keep it from clotting? Oh, this facility (where I have been working for six months) doesn't use heparin. All its arterial sheaths have to be hooked up to pressure bags to keep them from clotting. I am utterly horrified-- turns out nothing clotted and he was fine-- and then humiliated beyond reason. The charge nurse comes into the room and asks if I have much experience with sheaths. (Basic sheath management is taught in nursing school and learned hands-on during the first week or two of any ICU career, since every ICU with a cath lab gets thirty of them a week.) I stare at my hands, face burning, and wait to die.
I insist on writing up the incident report with the charge nurse. I kind of want to puke. The other nurse comes back every five minutes to tell me about another thing she found that I did wrong/didn't do/should have cleaned/should have told her in report. Some of the stuff is truly piddling. She's angry, but rightfully angry, because she got shafted. I also got shafted. I look out the window, where some kind of fluffy tree is shedding its down into the breeze, where it drifts lazily through the air over the highway and makes the world outside look hot and slow. The hospital seems to be immersed in golden brilliant syrup, an ocean of something too heavy to inhale. If I stepped out into it and held my breath, I would gradually ascend to the surface, a big human bubble rising through viscous light.
I shake myself out of it. Day six of seven is full of weird little moments like this. I am very tired and I want to breathe air that isn't filtered. The CRRT machine beeps and I empty its four-gallon bag of pee.
The pt has a drain tube in her abdomen that collects oozing, gloppy tan stuff as it pours from her abdomen, where her colon suffered two recent surgeries after a perforation. (The subsequent infection is why her kidneys are so fucked up.) I can't tell if it's pus or not and I'm a little worried. I page the GI physician's assistant, and am treated to an amazing story: apparently the colon, when shocked, forms a thick brown crust around itself called a rind, which later liquefies and oozes away. Since she's starting to recover, the rind is dissolving, and the halfway-open incision on her belly is giving it a place to drain to, mostly into the drain itself. The sixty mLs of tan phlegm I've been pouring out every hour are, apparently, liquefied traumatic colon rind. I know what I'm naming my next garage band.
I educate the pt's family extensively on renal health and infection processes. They all look tired and bruised. I bring them coffee and very gently ask the daughter to take her father home and have him get some sleep. He agrees to go, and kisses his wife's forehead goodbye. She squeeze his hand back, the first purposeful movement we've seen since she got sick. He cries hysterically and kisses her hand over and over. Their daughter guides him carefully out of the room to the waiting transport wheelchair that I've called to carry him to the car. I promise to call if anything changes, and he says he will be back in two hours. The daughter quietly tells me that if he falls asleep, she won't wake him up unless I call.
She really is getting better. I think she stands a chance.
There is a potluck in the break room. I manage a ten-minute break, load up on quinoa salad and lettuce salad and hummus, and quietly mourn the huge pancit feasts of my previous facility. Food's pretty good though. I cram it down, bitch a little about my day, get back to work. As i leave the break room a coworker comes in with a flan in a cake pan, which he dramatically inverts onto a plate. It's not a flan at all, it's a butthole-textured, donut-shaped jelly cushion used in surgery to keep pressure off patient's faces while they're lying face down. I laugh so hard I fart.
I give an uneventful report, change all the CRRT bags, and stagger to my car. My sister, who is in nursing school, has texted me: her friend from her rock-climbing days in Yosemite died yesterday in a failed base jump. I call her up and listen to her work through it as I drive home. She's a CNA when she's not in class, and she's calling me from the break room at work, crying. Ten minutes later somebody comes to get her because one of her pts has had a big bowel movement. I remind her that I'll see her at the end of the month and we say goodbye, neither of us admitting that today all our goodbyes feel a little like freefalls, because death and horror have become so familiar to us that we only notice them when they happen suddenly at the end of a plummeting drop.
The neurodegenerative guy was amazingly improved by the administration of pain meds overnight. Even his swallow was stronger (or else, quite possibly, he's so fucked up that he can't tell when water slides into his lungs and doesn't bother coughing), so tomorrow he's gonna get a barium swallow study-- swallowing barium-enriched fluids in front of an X-ray-- and if he passes that he can eat again. Crossing my fingers for you, dude.
Also got a PICC line in him, which is a long IV that goes all the way up your arm into your heart, allowing us to give you much stronger and more concentrated medications without injuring or burning your veins-- things like potassium, which is very painful given through a peripheral IV, and total parenteral nutrition aka IV food. Palliative Care came by and talked to his brother about his end-of-life wishes and the possibility of transferring him back to his adult family home on hospice, where he can live out the rest of his days with his treatment focus being comfort rather than recovery. Physical Therapy has a hard time working with him because he has so much pain.
He apologizes every time he asks for anything, or anything is offered to him. He is pathetically grateful and wary in a way that reminds me of an abused dog, and I asked the social worker if anything needed looking into. We agreed to defer any investigation until the psych team came by to see him, since he'd had no psych meds for days and is technically schizophrenic. Sure enough, he was having a massive onslaught of hateful and abusive voices telling him that he was a bad patient and deserved to die and that the people here were waiting for him to go to sleep so they could hurt him. Jesus motherfucker. We started him on orally-dissolving cheek-absorbed olanzapine to help him. It's really easy for things to slip through the cracks, but I could kick myself for not pushing sooner for other psych med vectors.
Meanwhile, I replaced my old bradycardia dude with a new guy from the cath lab, a fifty-year-old man with a history of morbid obesity, prior V-fib arrest, two cardiac stents, heart failure, diuretics and sodium restriction, diabetes, chronic renal insufficiency, and a pacemaker. He and his whole family reeked of cigarette smoke and not one of them weighed less than a Ford pickup. "Genetics," he said. "My bad luck. Dad had a bad heart too." I mean, no. It's not genetics. You might be a nice dude, but you're also fat as hell and it's literally killing you. Your blood is so sugary it's shredding your heart from inside out and your blood fats are so high that butter chunks the size of thimbles are bobbing in your aorta, and THAT, my friend, is why you're dying.
He had another stent placed, a 98% OM occlusion roto-rootered out. Lingering reperfusion pain. Nitroglycerin, morphine, and a nice neighborly dose of ativan fixed him right up. Still had the arterial sheath in his groin where they'd gone in, done up nice and neat with a syringe of heparin taped to it and the line clamped, presumably full of anticoagulant. Orders to remove it two hours after the last bit of anti-clotting agent went in. He complained nonstop about having to keep his leg straight, which I understand sucks, but also which I understand is LESS horrible than 10/10 crushing chest pain with blue-lipped shortness of breath. Maybe my priorities are fucked.
After that it was just putting out fires for a while, but sooo many fires. The next pt down the hall was receiving continuous renal replacement therapy, a sort of constant bedside low-grade dialysis that requires a one-to-one nurse who can constantly monitor and adjust it. Nobody else on the floor besides that nurse was checked off to handle CRRT, but I've done it at other facilities a million times, so the charge nurse asked if I could break the CRRT nurse for lunch. No big, done. Then gave another nurse a break-- I've had both of her pts before and knew them well enough to need very little report.
Stent guy wanted lunch, but declared that he hated hospital food. Family offered to go get him something to eat. "I want one of those bacon crab mac and cheese plates from Cheesecake Factory and an order of crispy egg rolls," he said.
"I'm so sorry," I cut in, "but both of those are definitely off the menu. Let's see if we can come up with something better for you."
"Why can't I eat what I want? I'm sick, I need comfort food."
"Sir, you just had a heart attack."
He looked at me like I had just started speaking Urdu. "...And?"
Family left with orders not to bring him ANYTHING and a very pointed hint that they might want to attend his meeting with the nutritionist tomorrow.
Pt ordered a burger from the hospital menu for dinner. Did not want light mayonnaise. Angry that the burger would not include cheese. Asked if he could have three burgers, hold all the veggies. Dietary declined and pointed out that this would put him far over his daily salt intake limit. Pt stewed for an hour, then called his mother and asked her to sneak him a cheesecake.
Darwin is coming for you, sir.
At this point, exhausted, I went into neuro guy's room to give him a tylenol (paracetamol) suppository, his IV antibiotic, and his IV metoprolol. The cheek-dissolving schizophrenia med was nowhere to be found; I messaged pharmacy to have it sent up. Everything was due at 1400, an hour before shift change for the eight-hour nurses (not me) at 1500, so there was a line for the drug machine. He was pooping in his bed, and his previous IV medication wasn't done yet, so I figured I would go take a lunch nap for thirty minutes and come back at 1445 to finish everything.
At 1440 the charge nurse woke me up and told me I would be taking the CRRT pt at 1500, checked off or no, because that nurse had to go home and there wasn't anyone else to cover. Fuuuuuuuuck. I went and gave report to the oncoming nurse, apologizing for the state of things, putting the cheek-dissolving medication from the tube station straight into her hand, and helping her clean and turn the guy (who had finished pooping). Then I dashed over and took the world's most intense report on the CRRT pt, who was preparing to have her CRRT run ended so that tomorrow she could have normal dialysis. CRRT is mostly the same wherever you go, but the charting varies a bit.
Oncoming nurse for my other pts comes into the room, raging. She is very upset that I left her so many chores to do. The room was messy, the meds weren't given on time, the orders weren't cleaned up, etc etc. I stare at her in bewilderment. Did I not tell her explicitly that I got ambushed with a pt exchange? I walked her through all of this, I know I did. I helped her clean up the guy. What is happening.
Oh. That sheath I was going to pull at 1500, the one that was heparin-filled to keep it from clotting? Oh, this facility (where I have been working for six months) doesn't use heparin. All its arterial sheaths have to be hooked up to pressure bags to keep them from clotting. I am utterly horrified-- turns out nothing clotted and he was fine-- and then humiliated beyond reason. The charge nurse comes into the room and asks if I have much experience with sheaths. (Basic sheath management is taught in nursing school and learned hands-on during the first week or two of any ICU career, since every ICU with a cath lab gets thirty of them a week.) I stare at my hands, face burning, and wait to die.
I insist on writing up the incident report with the charge nurse. I kind of want to puke. The other nurse comes back every five minutes to tell me about another thing she found that I did wrong/didn't do/should have cleaned/should have told her in report. Some of the stuff is truly piddling. She's angry, but rightfully angry, because she got shafted. I also got shafted. I look out the window, where some kind of fluffy tree is shedding its down into the breeze, where it drifts lazily through the air over the highway and makes the world outside look hot and slow. The hospital seems to be immersed in golden brilliant syrup, an ocean of something too heavy to inhale. If I stepped out into it and held my breath, I would gradually ascend to the surface, a big human bubble rising through viscous light.
I shake myself out of it. Day six of seven is full of weird little moments like this. I am very tired and I want to breathe air that isn't filtered. The CRRT machine beeps and I empty its four-gallon bag of pee.
The pt has a drain tube in her abdomen that collects oozing, gloppy tan stuff as it pours from her abdomen, where her colon suffered two recent surgeries after a perforation. (The subsequent infection is why her kidneys are so fucked up.) I can't tell if it's pus or not and I'm a little worried. I page the GI physician's assistant, and am treated to an amazing story: apparently the colon, when shocked, forms a thick brown crust around itself called a rind, which later liquefies and oozes away. Since she's starting to recover, the rind is dissolving, and the halfway-open incision on her belly is giving it a place to drain to, mostly into the drain itself. The sixty mLs of tan phlegm I've been pouring out every hour are, apparently, liquefied traumatic colon rind. I know what I'm naming my next garage band.
I educate the pt's family extensively on renal health and infection processes. They all look tired and bruised. I bring them coffee and very gently ask the daughter to take her father home and have him get some sleep. He agrees to go, and kisses his wife's forehead goodbye. She squeeze his hand back, the first purposeful movement we've seen since she got sick. He cries hysterically and kisses her hand over and over. Their daughter guides him carefully out of the room to the waiting transport wheelchair that I've called to carry him to the car. I promise to call if anything changes, and he says he will be back in two hours. The daughter quietly tells me that if he falls asleep, she won't wake him up unless I call.
She really is getting better. I think she stands a chance.
There is a potluck in the break room. I manage a ten-minute break, load up on quinoa salad and lettuce salad and hummus, and quietly mourn the huge pancit feasts of my previous facility. Food's pretty good though. I cram it down, bitch a little about my day, get back to work. As i leave the break room a coworker comes in with a flan in a cake pan, which he dramatically inverts onto a plate. It's not a flan at all, it's a butthole-textured, donut-shaped jelly cushion used in surgery to keep pressure off patient's faces while they're lying face down. I laugh so hard I fart.
I give an uneventful report, change all the CRRT bags, and stagger to my car. My sister, who is in nursing school, has texted me: her friend from her rock-climbing days in Yosemite died yesterday in a failed base jump. I call her up and listen to her work through it as I drive home. She's a CNA when she's not in class, and she's calling me from the break room at work, crying. Ten minutes later somebody comes to get her because one of her pts has had a big bowel movement. I remind her that I'll see her at the end of the month and we say goodbye, neither of us admitting that today all our goodbyes feel a little like freefalls, because death and horror have become so familiar to us that we only notice them when they happen suddenly at the end of a plummeting drop.
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