Crowbarrens, chest tubes, and death on the ICU

People die on the ICU.

This is just a fact of life: we can’t save everybody. Bodies fall apart if enough bad things happen to them. Sometimes we can keep part of the body alive, but not the rest; sometimes we can support consciousness even when the body is doomed, although eventually even consciousness will fade. More often, we can keep the body running even while the brain is completely dead.

You’ll notice that, with other organ systems, we use different terms than with the brain. If your kidneys have some working tissue, but aren’t strong enough to get your blood really clean, you have renal failure. If your kidneys are so fucked up they shrivel into black raisins and you never pee again and you depend on a dialysis machine to clear out all your nitrogen waste products forever, we call it end stage renal failure, not renal death.

If your liver is a huge lumpy pile of scar tissue and blood can’t flow through it at all, you aren’t experiencing liver death (although you will soon die unless you get a new liver), you’re in end stage liver failure. If your lungs are full of gross shit and require mechanical assistance to get oxygen and carbon dioxide in and out of your blood, you are in respiratory failure; if your lungs are filled with scar tissue and nodules and all the cilia are burned out and every breath uses up more oxygen than it gains, you are in end stage respiratory failure. All of these things lead directly to death, although we’ve learned to cheat them a little better over time, but they are not death.

We also talk about heart failure, in which the heart can’t move blood well enough to maintain equilibrium without medical help. We even talk about end stage heart failure sometimes, although this mostly means this person is about to be dead. The true end stage of heart failure is cardiac death.

We call it death, because for a very long time, the lack of a pulse was death. There was no way to get it back. Once you crossed that line, you were gone.

But we’ve learned to cheat even that death, sometimes, if we’re lucky. We can, if we’re willing to break ribs and insert tubes and flood the body with toxins, restart the heart. We can even support a fatally wrecked heart for a while with ventricular assist devices. What was once death is now closer to failure.

So if we’ve blurred the line between life and death, what’s left? Is there anything that can be so damaged that we can’t compensate for it? Is there anything that truly goes beyond failure into death?

Whitney the Muslim

I apologize for the brevity of this post. For those of you that follow my scrawlings on Something Awful, I’ve been doing an AMA for the last twenty-four hours on the BYOB forum, which has diverted just a little of my writing powers.

I did manage to rant with embarrassing fervor about fruit that I like.

Anyway.

Sometimes the ICU runs like you expect it to: occasional periods of panic, lots of gross chores, and a slump around 1600 when you can catch up on your charting. Sometimes it gets a little crazy, and if you have a really rowdy pt with a lot of things going wrong, you can easily spend a whole shift on your feet and do all your charting after you’ve passed your pt to the next shift. And sometimes, the whole ICU loses its goddamn mind at once, and all your pts are desperately high-acuity and breaks only happen if everyone works together, and staffing calls random people on their days off and begs them to come in—not to take pts, but to serve as an extra flex nurse, just to help people get all their chores done.

When this happens, you have to be a special kind of dumbass to actually answer your phone, let alone come in extra. Unfortunately for me, I am that exact kind of dumbass. That week, I worked a lot.

Wishbone, Leah, and the Return of Crowbarrens

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

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

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

Week (actually) 5 Shift 1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Modern medicine is nothing short of a fucking miracle.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Week 3 Shift 3

Arrived to find my assignment slightly shifted. The unfortunate peritoneal dialysis guy spent all morning waiting to see if they could stent him this afternoon, so he was super low acuity and they paired him with a very high-acuity pt down the hall, a different guy who required a sitter to keep him from pulling out all his lines and tubes. As a result, I only interacted with him as the next-door nurse, filling in cracks for the nurse officially assigned to his care. In the meantime, the patient patient (hurr hurr) twiddled his thumbs until cardiology decided that they would brave his awful vasculature and many allergies, and dig out whatever was clogging his heart.

Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.

This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.

The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.

It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.

So down he goes for his cath.

My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.

(We typically refer to this procedure as an EGD, for obvious reasons.)

So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.

She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.

The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.

She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.

Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.

Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.

This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.

Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.

And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?

If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.

Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.

While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.

Well, maybe a few people. But judgement like that isn’t mine to make.

I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?

Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.

No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.

Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.

Favorite memories of the two departing nurses:

--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.

--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.

Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.

The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?

I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.

Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.

She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.

Hopefully I won’t die of anaphylactic shock.

Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.

If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.

There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).

My stories are short stories. My endings are reports at the end of shift.

Week 3 Shift 1

I totally expected to get Crowbarrens back today, but I guess some other poor sucker got that assignment. I heard him yelling as soon as I got on the unit—I CAN’T BREEEEEATHE—but I ended up at the other end of the hall from him.

One of my pts is a lady with severe COPD from years of smoking. Her burned-out, scarred-up lungs barely open when she tries to breathe, and gross germy crap builds up in all the crevices and now she has pneumonia. Between her baseline COPD (which forces her to wear an oxygen cannula at home) and her plugged-up lungholes, carbon dioxide piled up in her body until her blood became acidic and her brain started to shut down from as a result.

It is actually pretty easy to keep your oxygen levels livable. Oxygen exchange from the little air sacs in the lungs to the blood vessels that snuggle up to them is really efficient, and even depleted air and blood have enough oxygen to keep you going for a little while. The hard part is getting rid of carbon dioxide, which is what actually triggers your breathing impulse—your oxygen level at normal health stays totally steady between breaths, but your CO2 rises and falls as you breathe, and between each breath the CO2 makes your blood more acidic until your brain triggers the next breath. Breathing is your body’s primary method of controlling its acidity, which is why I roll my eyes at fucking “alkaline diets” because a variation of a few tiny points of acid buildup can make you gasp like a carp.

I mean, yeah, you can make your whole body heavily alkaline if you puke/shit/breathe too much acid away. You can make yourself alkaline by hyperventilating. We call it ‘hyperventilating’ and not ‘hyperoxygenating’ because what makes you feel dizzy and sick is not too much oxygen, it’s too little carbon dioxide, and the process of removing poison gasses from an area is called ventilation.

Cancer and other major diseases tend to cause your blood to become acidic. This is because they are expensive for your body to maintain and compensate for. Cancer is hungry (all those cells multiplying out of control) and infections take tons of energy to fight, and when your body starts to get depleted of its energy sources, it’s forced to rely on a backup mechanism of energy production that produces tons of lactic acid. Which, of course, raises the acidity of your body. Making your body alkaline somehow would just mask the symptoms of the acidosis, if you could actually achieve it without your body just adjusting your breathing rate to maintain equilibrium.

At high acidity levels, many of your body’s proteins—that is, the power tools of your body, enzymes that look like molecular wrenches made for specific tasks—are unable to operate properly. Your brain fogs up and your organs start to take damage. Enough carbon dioxide, and you enter a state of narcosis and can’t be awakened.

When this happens because of carbon dioxide retention, we start by improving the ventilation. This usually means pressure-supported breathing, to force open the little air sacs and prevent them from collapsing during expiration, which would trap all that newly-CO2-laden air down in the lung where it can’t escape and be replaced with oxygenated air. Sometimes this means intubation, which allows us to tightly control pressure and volume; sometimes it means a bipap mask, which puffs air at two different pressures during inspiration and expiration, but is uncomfortable as all hell if you aren’t used to it.

So this lady is wearing a bipap mask to clear out her CO2, and is sleepin’ it off. She has restless leg syndrome, and apparently restless-everything syndrome, because at baseline she twitches constantly while sleeping (per her medical record) and let me tell you, she’s in there jerking around so hard her arms and legs keep flopping out of bed. She looks like a cat dreaming about fifty mice in a box.

My other pt I will give you only minimal information about, because they and their family members are likely to sue the hospital. Their radiology reports after a traumatic accident seem not to have been read correctly, and somehow everyone missed a large fracture, which caused them incredible pain for days before someone reviewed the case and discovered the fracture. One major surgery later, they are finally improving, but one of their relatives is an MD specialist and every time I go in the room I get cross-examined about medications, procedures, and test results. They are clearly looking for conflicting information to contribute to their lawsuit, and it is really unpleasant and pointless.

Pointless because when they take this case to court, they have everything they need to make their case—the exact number of times the pt used their pain-medicine button today (Patient-Controlled Analgesia is rad) really doesn’t have much bearing on whether the hospital is liable for the delay of care last week. I can’t give them any of the information they would need for legal purposes, and they have full rights and access to their entire medical record on request anyway. All I’m allowed to tell them is what I’m doing and what I’ve done—not what previous shifts have done, not what the doctors think, not what the full plan of care is—because as a nurse it’s outside my scope.

This is not exactly bolstering my pt’s trust in me as a caregiver. It sucks real bad.

Fortunately the social worker here is an angel clothed in human flesh and she spent about an hour in the room talking to the pt and their family. We are kind of teaming up to help make sure the “little things” get taken care of—parking validations, a chair for the family member on the phone by the hall window, calls to insurance companies and whatever else we can do. We’re not trying to cover up the fact that legal discussion is totally appropriate for their case (if I were them I would be looking for an attorney too), just trying to help them find some dimension of care that they don’t have to feel totally on guard about. This might sound disingenuous, but the fact is: after a bad outcome, the breach in trust between provider and patient can be incredibly detrimental to the pt’s further recovery. There’s a lingering fear that you might recognize from the last time you had to send back a dish at a restaurant: now that I’ve spoken up, even though I was in the right, will the servers spit in my food?

Which means that the little things, the pampering and attention to detail, are especially important for pts who have, or feel that they have, had wrongs done to them. It’s emotionally strenuous to be lying in bed with an awful disease or injury, thinking about how someone dropped the ball and caused you more pain and suffering, and wondering if the other staff will neglect or injure you as soon as you let down your guard. Like, even if you’re fucking crazy and nobody did a damn thing to you, your anxiety is gonna spike out the roof and you’re going to drive your caregivers crazy trying to monitor their every move… which sometimes means you’re cruising WebMD at the hospital because you feel like you need to provide your own care.

And, I mean, that loss of trust is sometimes legit. If somebody lops off the wrong leg or injects your kid with poison, you’re going to be extremely distrustful of medicine in general for a while, and nobody can fucking blame you. But you’re still in that awful helpless position of knowing that you still need medical care, and there’s the rub.

So if your immediate care providers, your nurses and other staff, can win your trust back a little at a time, and give you a little bit of a chance to relax, that’s a big deal. If you get every medication explained, bottomless ice water that never seems to hit empty, advance notice every time anyone touches you, and the question what else can I do for you every time anyone leaves your room, you start to forget that you’re supposed to be on guard, and you get to feel for a little while like someone is genuinely watching out for you again.

Is this time-consuming in the extreme? You fucking goddamn bet. Are you gonna get the Disney treatment if my other pt is on the verge of coding? No fucking way in hell. Am I still going to meet your basic care needs and tell you what’s going on in excruciating detail, even if I don’t have time to fluff your pillows and make caring faces at you? Well fuck, I’m writing all this.

Anyway. The day got better once that connection was made. The family is sleeping now.

A pt down the hall came in crazy—an alcoholic who quit in the ‘90s by switching to speed and who has recently been using lots of PCP. His adult son apparently got a weird phone call earlier today and went by to check on him, found him seizing, and called 911. Earlier this shift the PCP guy woke the hell up on full sedation, self-extubated, kicked his son in the head, bit a nurse, and gave himself a head laceration by beating his face against the side of the bed. The son came staggering down my way, shaken up pretty hard, terrified that his father would die and livid that his father was putting him through this mess again. He shored up at my end of the hallway and told me the whole story of his father’s sad and miserable life, while I charted and let him vent.

I mean, I got a shitty family too. Not angel-dust punch-a-nurse shitty, but shitty enough that I know what that helpless anger and fear feels like, and how useless it is when people try to give you advice or even really react emotionally to the situation (which just makes you feel ashamed of Dear Old Dad again). All I want when I’m venting is for somebody to laugh incredulously at how dumb Dear Old Dad was this time around, and acknowledge that the whole situation is shit but what can you do. I hope it’s the same for this dude. He certainly seemed to feel better after getting it off his chest, and by the time the RT team (plus five adorable duckling students) got his dad re-intubated, he was back on his metaphorical feet.

It sucks, man. The dude looked a little like Chris Pratt with an extra twenty pounds. I could definitely put myself in his shoes and I wish I could fix his dipshit dad for him.

About an hour later somebody called me down to Crowbarrens’s room to “talk to him,” which is both the highest possible praise and the worst possible fate. We had a nice conversation and then I spent about twenty minutes trying to teach his nurse for the day about limit-setting and boundaries. I think I really scared him the other day when I lost my cool at him, though. He was very upset that I wasn’t his nurse (see: unhealthy dependence as patient management tactic) and even more upset when I told him (this is a lie) that I deliberately didn’t take him today because I was really bothered by the way he yelled at his wife, and that if he could earn back my trust I’d be glad to take him as a pt again. He nodded eagerly. No idea whether this will impact his actual behavior in any meaningful way, but wouldn’t it be nice?

He only wants me as his nurse because I made him think that he “earned” my positive regard, and now he fears losing it. This is a shockingly effective tactic with patients who suffer—and make staff suffer—with control issues. I learned it from my mother’s second husband, who was a prison guard for a while, and I have used it with a number of really difficult pts. I feel ethically conflicted about it, but honestly, by the time somebody reaches the point that you have to make them worry about losing your respect so they won’t punch you, they probably aren’t capable of having healthy human relationships.

(This will backfire violently if Crowbarrens actually shapes up, because then I will be his nurse forever in perpetuity until he dies, which will probably be three days before I start collecting social security. Albatrosses live forever.)

Another fun pt story that’s been going on here lately: a woman with a history of ETOH (the polite way to say alcoholism) who is in catastrophic liver failure and keeps bleeding out. She had some transfemoral procedure—I think a liver embolization for a major bleed—and the insertion site at her groin has re-bled five times now. Violently. Spurtingly, even. She has almost no platelets, negligible clotting factors, and hepatic encephalopathy so intense she thinks she’s in Guam being tortured by insurgents (??????). Today she was transferred back from the medical/surgical floor with another rebleed, a softball-sized hematoma in her groin that pulsed like an alien egg sac. I wonder how much longer until the blood bank cuts her off—she’s had something like, what, seventy-five blood products in the space of a month? And she’s end-stage liver failure and an active drinker, so she’s not eligible for a transplant. This will not end well.

On the bright side, all the suction modules in her room will get a nice thorough cleaning, because she spurted blood everywhere in that general vicinity. Nobody goes in that room without every piece of protective gear they can find—she’s also Hep C positive.

Remind me some time to go into the mechanisms of alcoholism and liver failure and how it makes you bleed, especially from the throat and the intestines. I am too tired to keep typing anymore.

Week 2 Shift 2

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.